Description |
Working for an organization with the size and resources of Kaiser Permanente Southern California means having the potential to positively affect the health and well-being of entire communities. That's because each of us-from our financial professionals and IT team members to our RNs and physicians on the front line of care-shares a commitment to providing the best possible care experience. One of the most diverse regions in the country, Southern California offers everything from quaint coastal communities to bustling urban cities, high desert plains to snowy mountain peaks. Here, you'll find the cultural, lifestyle, and recreational amenities to complement your work and your life. Come discover the resources, support, and opportunity you need to build the career you've always wanted.
Developing, managing, and providing the utilization management programs in a service area or medical center. Develops and manages programs that emphasize appropriate admissions as well as concurrent and retrospective review of care. May also be responsible for other integrated functions such as discharge planning, case management program, outside utilization review program, transportation coordination and extended care coordination to promote a centralized, coordinated interdisciplinary process in the continuum of care.
Essential Functions:
- Oversees adherence to quality of care and utilization standards by reviewing documentation and analysis of utilization data.
- Develops standards of care and quality improvement activities based on regulatory standards.
- Serves as a resource to senior management as UM and CM experts.
- Develops regional programs based on regulatory requirements.
- Collaborates with program re-design to meet targeted utilization outcomes.
- Provides clinical and regulatory expertise for contractual reviews and for regional regulatory surveys.
- Provides oversight to design, develop, implement and monitor UM and Case Management programs to meet regional utilization goals while maintaining customer satisfaction.
- Acts as a resource to Directors, Assistant Administrators, Ambulatory Medical Staff, SCPMG, and external regulatory agencies for all issues relating to UM.
- Analyzes and reports significant utilization trends, patterns, and impact to appropriate departments.
- Serves as a contract liaison for regional issues pertaining to contracts and vendor, outside medical and transportation.
- Provides education and training to UM Directors, Physicians, and Case Managers to ensure smooth operations in UM and CM.
- Makes significant contributions and or provides clinical and technical leadership to high visibility projects to identify and resolve issues of strategic importance to the organization.
- Interfaces regularly with senior management to produce timely and valuable results.
- Sets the strategic direction of projects.
- Determines goals and priorities with management team sponsor.
- Establishes team membership and negotiates time commitments and resources.
- Develops proposals for clients outlining proposed project structure, approach, and work plan.
- Provides staff leadership to project teams, as well as manages work of outside consultants when needed.
- Designs research plans for data gathering and analysis; participates significantly in interpreting analysis and developing action plans accordingly.
- Produces or oversees development of written materials for senior executives and other key clients.
- Compliance and Integrity: Models and reinforces ethical behavior in self and others in accordance to the Principles of Responsibility; adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty; shows consistency in words and actions; follows through on commitments.
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Requirements |
Basic Qualifications:
- Bachelor's Degree in nursing or business administration, health care administration or public health administration or other related field required.
- Master's Degree strongly preferred.
- Current California RN License required.
- Typically five (5) or more years of experience in a clinical setting.
- Demonstrated ability to determine the key business issues and develop appropriate action plans from multidisciplinary perspectives.
- Demonstrated ability to conduct and interpret quantitative/qualitative analysis.
- Proven leadership skills in project management and consulting.
- Must exhibit efficiency, collaboration, and candor, openness, and results orientation.
- Demonstrate knowledge of the Nursing Practice Act; JCAHO, NCQA, Title 22, Federal and State Health Regulatory requirements, operations of KP health policy trends.
Notes:
- May need to work occasional Saturdays in lieu of a regular work day.
Primary Location: California-Pasadena
Scheduled Hours (1-40): 40
Shift: Variable
Working Days: Mon, Tues, Wed, Thurs, Fri, Sat
Working Hours Start: 9:00 AM
Working Hours End: 6:00 PM
Schedule: Full-time
Job Type: Standard
Employee Status: Regular
Employee Group: Salaried Employees
Job Level: Individual Contributor
Job: Quality Management
Public Department Name: Utilization Compliance
Travel: No
Job Eligible for Benefits: Yes
External hires must pass a background check/drug screen. We are proud to be an equal opportunity/affirmative action employer.
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