Job Description

RN Supervisor Um Prior Auth

Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation's largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 158 hospital-based locations, in addition to its home-based services and virtual care offerings.

The posted compensation range of $53.46 - $79.52 /hour is a reasonable estimate that extends from the lowest to the highest pay CommonSpirit in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. CommonSpirit may ultimately pay more or less than the posted range as permitted by law.

As our Supervisor of Utilization Management (UM), under the guidance and supervision of the department Manager/Director, you will be responsible and accountable for coordination of services for Mercy Medical Group and Woodland Clinic Medical Group through an interdisciplinary process that provides a clinical and financial approach through the continuum of care.

Every day you will promote the quality and cost effectiveness of medical care by ensuring department staff are applying clinical acumen and the appropriate application of policies and guidelines to Managed Care prior authorization referral requests. Under general supervision, this position is responsible for coordinating the daily operations of the UM Pre-Authorization team in order to ensure requests are processed in a consistent and timely manner while observing regulatory guidelines.

To be successful in this role, you will have a strong knowledge of Utilization Management, strong leadership skills, and a passion for high-quality patient care.

As a remote employee, we will provide you with the equipment needed to work from home, including a laptop, docking station, dual monitors, and accessories.

This position is primarily work-from-home within driving distance of Sacramento, CA, as there may be occasional onsite meetings.

This position will work rotating weekends.

Responsible for day to day operations of the Pre-Authorization team to include timely response and appropriate evaluation of referral reviews, correct selection of criteria, accurate prep to the UM Physician reviewer when indicated, timely verbal and written documentation, and completion of the file.

Ensures adequate staffing and assignments and adjusts workflow as needed to meet department goals. Manages team schedule including requests for time off and assurance of coverage during physician office hours.

Organizes, structures, and chairs a minimum of one pre-authorization meeting per month, including other staff as appropriate.

Motivates and coaches staff to include new-hire training, problem solving, and special projects. Assists manager with performance activities to include monitoring, coaching, educating, and providing feedback to team.

Ensures UM Physicians are provided the relevant information needed to accurately review a referral. Fosters the relationship between the Pre- Authorization team and the Medical Director and Physician Reviewers.

Tracks cost savings from activities over time to evaluate success of programs. Maintains or removes programs based on organization and department goals. Develops reports for leadership as required.

Required:

• Five (5) years clinical experience
• Three (3) years Utilization experience in health plan/UM operations, acute or subacute utilization review
• Bachelors degree, or equivalent experience
• Clear and current CA Registered Nurse (RN) license
• Ability to demonstrate leadership and management skills
• Knowledge of all applicable federal and state regulations as well as accreditation standards
• Demonstrates a working knowledge of Utilization Management, UM review processes, and regulatory requirements
• Must have the ability to monitor, compile, report and analyze data/statistics
• Requires excellent human relations, interpersonal and oral/written communication skills
• Able to recognize and address the needs and concerns of customers
• Ability to interact with all levels of the organization as well as with external contacts
• Requires good knowledge and skills with Microsoft Office (ie: Word and Excel) and other computer information systems and applications

Preferred:

• Seven (7) years UM experience with Charge/Lead/Supervisory/Management experience in Utilization Management department preferred
• Previous prior authorization experience strongly preferred
• Managed care experience preferred
• Experience working with health plan auditors preferred
• Working knowledge of InterQual preferred
• Knowledgeable of NCQA and ICE preferred

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