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Under the direction of the Director of Utilization Management, the UM Inpatient Clinical Supervisor RN is responsible for supervising the functions and activities for all inpatient clinical level positions within the UM Department. The UM Inpatient Clinical Supervisor will work in a coordinated effort with the Manager of Health Services to ensure a smooth, efficient and productive operations within the UM Department, as directed by the Director of Utilization Management. This position will work closely with the Chief Medical Officer and Medical Director(s) in the smooth and efficient operation of the referral and outpatient clinical decision making process. The UM Inpatient Clinical Supervisor is responsible for supervising the Inpatient clinical staff within a licensed health maintenance organization (HMO). This position will also be responsible for insuring proper training of UM Nurse RN, Social Worker, and concurrent review clinical staff and for the proper review of concurrent, long term and intermediate levels of care utilizing appropriate clinical guidelines for inpatient medical necessity clinical decisions. The UM Inpatient Clinical Supervisor will closely monitor inpatient utilization trends and patterns.
• Supervise the appropriate UM Nurse RN and Social Worker staff to remain in compliance with UM guidelines and Policy and Procedures; Responsibility • Works closely with the UM Clinical Trainer to develop training material and train UM staff as appropriate regarding use of the all platforms and the core adjudication system as it relates to the UM process; • Provide oversight for specialty and ancillary service referrals using established criteria for purposes of pre-authorization of payment. • Reviews decisions regarding hospital admissions and length of stay, and outpatient procedures for all care delivered to the membership as related to coordination of services upon discharge; • Assists with coordinating discharge planning activities with facility discharge planners to facilitate members transitions of care; • Benefits interpretation to include coordination of care for medically necessary services that are not covered under the Plan e.g. CCS, Mental Health, Long Term Care, State Waiver Programs. • Works closely with the Case Management to facilitate needs for members identified as High Risk or requiring coordination of services; • Assist the UM clinical staff in the review of claims for the accuracy and appropriateness of billed charges; • In coordination with the UM Auditor/Analyst staff, perform periodic audits of the UM Nurse RN and Social Workers of inpatient clinical decisions for appropriateness and accuracy of documentation and summarize and report the results of the audit; • Manage timecards, PTO, flex, and vacation schedules; • Assist Director of Utilization Management in the development and updating of UM criteria, guidelines, and policies; • Provide guidance to clinical staff regarding Behavioral Health and other mental health conditions regarding coverage and coordination of services with community partners; • Ensure coordination of medically necessary services within the plan and with community;
• Strong knowledge of the principles, techniques and practice of public and community health education, including the understanding of the theory and ability to apply knowledge of the basis of human behavior, the process of education, motivation and group work, and the relationships of cultural patters of human behavior; • Demonstrated knowledge of and skills in protocols for utilization management, discharge planning and/or case management; • Strong knowledge of acute care nursing principles, methods and commonly used procedures; • Strong knowledge of common patient disease processes and usual methods for treating them; • Thorough knowledge of medical terminology, hospital routine and commonly used equipment; • Knowledge of acute hospital organization and interrelationships of various clinical and diagnostic services; • Proven ability to effectively evaluate medical records of hospital admissions regarding continuing stay necessity, appropriateness of setting, delivered care, use of ancillary services and discharge plans • Proven ability to assess and judge the clinical performance of physicians and other health professionals; • Demonstrated knowledge of and skill in protocols of Disease Management;(E) • Knowledge of medical terminology and commonly used equipment • Knowledge of ICD10 and/or CPT coding; • Demonstrated thorough knowledge of health care delivery systems and HMO regulatory requirements, including DMHC and CMS compliance; • Strong analytical, assessment and problem solving skills with intermediate negotiation skills; • Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individual at all levels both inside and outside of company; • Ability to use tact and diplomacy to diffuse emotional situations; • Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards;
• Ensure proper clinical decision making or improper documentation as noted during internal or external auditing; • Train and conduct performance evaluations of UM inpatient clinical staff; • Coordinate training of staff within the Interrater Reliability Review Tool to all clinical staff, including CMO and Medical Directors to facilitate consistent decisions based on evidence based guidelines; • Provide input to the Director of Utilization Management regarding disciplinary issues; • Insure proper coordination with Medical Director(s), Pharmacy and other departments, as appropriate, in making sound clinical decisions; • Remains current with California Children’s Services benefits and guidelines for coordination of services; • Monitors and reports production and quality of work by outpatient clinical staff; • Works with staff to achieve production, timeliness, accuracy, and quality of work; • Summarize and prepare necessary production reports for management; • Act as clinical liaison with Member Services, Claims, MIS, and Provider Relations on referral data entry functions. • Works in a coordinated effort with the UM Health Services Manager and Program Manager to ensure the smooth and efficient operations of the UM processes; • Serves as a clinical liaison with contracted facilities and providers and participates in Joint Operations meetings to improve patient care and ensure access standards; • Remain current with Department of Health Care Services and Department of Managed Care policy implementation or revisions;
• Possession of a valid California R.N. nursing license and five (5) years of full-time experience as a registered nurse in an acute care hospital, or its equivalent, and one (1) year of previous utilization/quality management experience in a managed care setting; Bachelor’s Degree in Nursing or Healthcare Administration required Two (2) years of supervisory experience required CCM Certification preferred Possession of valid California Driver’s License and proof of valid State required auto liability insurance. Required travel up to 10% Bilingual (English/Spanish) preferred Ability to adapt to a rapidly evolving work environment; Work independently and manage multi-task responsibilities; • Demonstrated ability to commit to and facilitate an atmosphere of collaboration and team work; • Possess knowledge of payer source documentation requirements and governmental regulations affecting reimbursement; • Ability to supervise and mentor staff, analyze situations independently and make appropriate decisions; • Ability to prepare written reports and maintain accurate records; • Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards; • Advanced computer skills that include MS Office products ; • Demonstrate ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, business or employee information and make no disclosure of such information except as required in the conduct of business.; Demonstrated ability to multi-task in an interrupt-driven environment and complete assignments on a timely basis; • Strong attention to detail; work accurately and at a reasonable rate of speed;
Impresiv Health is a healthcare consulting and staffing partner specializing in operations management consulting and business optimization services for companies across the healthcare continuum. Started on the belief that a firm’s foundation could be built with a team of thought leaders and proven industry experts, we’ve established a company that delivers quick and efficient results for our clients. We offer strategic business and technical management consulting services, and a suite of staffing solutions.
Impresiv Health is a services partner with a focus on expediting time-to-value. It’s not just our goal to immediately deliver greater returns on your investment in us as a partner—it’s our reputation.
Travel Requirements: remote to start, then relocate to Bakersfield post Covid.
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