Our Client is a Medical Clinic seeking a Utilization Management Team Lead. This is a diverse role that requires a unique candidate. Responsibilities include:
- Serving as the Utilization Management (UM) team leader including directing, coaching and mentoring the UM Specialist staff members to ensure they are operating efficiently and effectively.
- Ensure there is timely and effective communication of information between the clinical staff and billing staff.
- Primary responsibilities include directly performing reviews of all admissions to the inpatient programs and oversees admissions to other clinical programs as indicated to determine clinical necessity and appropriateness in accordance with approved criteria, standards, or policy and procedure.
- Work effectively with insurance companies and efficiently obtain pre-certification for admissions and authorizations for continued stays.
- Provide oversight to and collaborate with the Glades Services UM/UR activities, collect the relevant data and incorporate data into the Center-wide UM/UR database.
- As a member of the utilization review committee, review the medical necessity of admissions, the appropriateness of the setting, the medical necessity of extended stays, and the medical necessity of professional services rendered, including the provision of drugs and biologicals.
- Review length-of stay on a case-by-case basis and provide input as to the appropriateness of continued stay, as may be required.
- Examine the need for, and utilization of consultations for appropriateness.
- Collect, monitor, and interpret indicators of clinical performance and provide data, reports or other useful information the Utilization Review committee.
- Oversees the UM team's preparation of charts, graphs, oral and written communications to satisfy internal/external reporting requirements.
- Develop, review, and/or revise as appropriate, the Utilization Review Plan.
- Perform clinical medical record review for medical staff using approved criteria. Perform other assignments and/or duties as may be required.
Teamwork: To make a habit of openly communicating, cooperating and collaborating. All staff members work together to achieve our vision. Managers create environments that encourage communication and support staff.
Customer Service: To treat every customer with respect and to provide individualized customer driven services in a dependable manner.
Integrity: To always pursue ethical practice, honesty and accountability.
Empowerment: To create an environment in which all levels of management and staff take responsibility for promoting a positive work environment with positive attitudes, shared respect and enthusiastic contribution to, and ownership of the Center's mission. Remove barriers to outstanding performance.
Performance Improvement: To continually seek opportunities for improvement and to encourage the development of personal and professional competencies.
Excellence: To perform with operational excellence by providing evidence based care and by designing and implementing an efficient infrastructure.
Innovation: To display flexibility, creativity and entrepreneurial spirit. Continue to support change as it encourages new ideas and approaches.
Cultural Competence: To be sensitive to and value the diversity of cultural beliefs, perceptions, ethnicity, language differences and religious practices of persons-served, their families and Center staff, and to recognize the influence of culture on the effective delivery of behavioral healthcare.
Safety: Services are provided in an emotionally and physically safe, compassionate, trusting and caring treatment/working environment for all persons served, family members and staff.
We are an equal opportunity employer and make hiring decisions based on merit. Recruitment, hiring, training, and job assignments are made without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, or any other protected classification. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance.