Manager Of Case / Utilization Management
Yoh Health Care (San Francisco, California)

Yoh Health Care has a direct hire opportunity for a Manager of Case / Utilization Management to join our customer in San Francisco, CA. 

This position manages, provides day to day services, and coordinates the overall direction of the Case Management, Utilization Management and Disease Management staff to ensure consistent development, implementation and maintenance of CM/UM/DM clinical services, policies and processes, and achievement of department goals and objectives. This position also manages regulatory audits and inquiries related to departmental services.

Major Responsibilities:
• Facilitates all aspects of the Case and Utilization Management programs and in the absence of the Director is responsible for oversight of the day-to-day activities within the Care Management area.
• Responsible for working directly with the Plan IPA’s/medical groups, community programs, state programs and hospitals to ensure coordinated, continuous cost effective quality health care for members.
• Coordinates the development of the Case/Utilization/and Disease Management programs, including improvement of current software and/or implementation of new software.
• Supervises the Case/Utilization/and Disease Management staff.
• Trains and orients existing and new staff.
• Performs clinical role for CM/UM/ and DM responsibilities approximately 30% of the time.
• Responsible for development and/or updates to Policy and Procedures.
• Oversees the UM/CM components of the annual medical group oversight audits conducted by the company, develops corrective action plans (CAP) if needed, and monitors CAP to ensure implementation., appropriate resolution and the reporting of such to Medical Director and QI Committee.
• Audits denial letters per procedure.
• Assists with development/improvement of UM/CM/DM metrics.  Prepares reports on utilization and CM/DM activities for plan management according to established schedules and format. Identifies patterns and trends and in collaboration with the Director of Clinical Services and Medical Director develops and implements corrective action plans, where necessary.
• Coordinates special projects that effect CM/UM/DM, such as Continuity of Care for the Young Adult (YA) phase-out.
• Be a source of expertise and leadership for the department and health plan as a whole. Assure availability of current medical management reference materials, periodicals and criteria guidelines for use by staff. Provides opportunities for staff in self learning and skill development.
• Ensure the privacy and security of PHI (Protected Health Information) as outlined in company policies and procedures relating to HIPAA compliance.
• Other responsibilities as assigned.

Skills:
• Demonstrate excellent leadership and analytical skills with ability to establish and motivate staff to achieve goals and objectives.
• Excellent inter-personal skills, ensuring development of effective programs that meet provider and member needs.
• Excellent written and oral communication skills.
• Ability to evaluate the quality of necessary medical services, and be able to acquire and analyze the cost of care.
• Ability to develop and maintain effective working relationships with all levels of staff, other programs, agencies, and the general public.
• Communicates effectively at all organizational levels and in situations requiring instructing, persuading, negotiating, consulting, and advising.
• Ability to assess resource utilization, cost management and negotiate effectively.
• Effectively utilizes computer and appropriate software.

Qualifications:
• Current unrestricted California RN license, required.
• Experience with utilization management/case management in a health care delivery setting – 3 years required, 5 years preferred.
• Experience in an HMO or experience in managed care setting, preferred.
• Knowledge of and experience with state and federal insurance programs, preferred.
• BA/BS in nursing, preferred.
• Master’s degree, desirable.
• Bi-lingual Spanish or Cantonese, desirable.

Discover all that’s possible with Yoh Health Care. Apply now.