Utilization Management Manager - AlohaCare

Apply on line at http://www.alohacare.org/Careers/Default.aspx

The Company:

AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all. This is accomplished with emphasis on prevention and primary care through community health centers that founded us and continue to guide us as well as with others that share our commitment. As Hawaii’s third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage to successfully build a healthy Hawaii.

The Culture:

AlohaCare employees share a passion for helping Hawaii’s most underserved communities. This passion for helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work/life balance, continuous communication and a generous benefits package.

AlohaCare’s leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs. AlohaCare has a strong commitment to support Hawaii’s families and reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect and trust with both our internal and external customers, we encourage open-door, two-way communication through daily interactions, employee events and quarterly all-staff meetings. AlohaCare’s comprehensive benefits package includes low-cost medical, dental, drug and vision insurance, PTO program, 401k employer contribution, referral bonus and pretax transportation and parking program.

These employee-focused efforts contribute to a friendly, team-oriented culture which is positively reflected into the communities we serve.

The Opportunity:

The Utilization Management Manager provides administrative oversight and monitoring of the utilization review activities including the Utilization Management Program (UMP) development and implementation. Supervises professional nursing staff performing utilization management functions for inpatient, outpatient, medical/surgical, behavioral health and home and community-based services; ensuring that members receive care and services that meet all contractual and regulatory requirements for quality, timeliness and access to care. Works with the Medical Directors to ensure availability of clinical guidance and support for clinical review staff. Implements the Utilization Management Program (UMP) to ensure that members receive care in the least restrictive setting by overseeing the consistent application of appropriately approved clinical criteria guidelines (e.g., MCG). Works with the Medical Directors, VP, Health Services, Director of Medical Management and Quality Improvement (QI) management, in the successful implementation of the Quality Improvement Program as it relates to MEDQUEST, CMS and NCQA UM requirements.

Primary Duties and Responsibilities:

• Manage the day-to-day operations while implementing the UM program and its role in the QI program.
• Implement appropriate processes to facilitate effective management of members with medical, behavioral and community health services in assuring service sites, levels of care are appropriate. Monitoring services provided for continuity, cost effectiveness, medical necessity, and timeliness. Makes recommendations to Director of Medical Management and Chief Medical Officer for improvement of processes and services.
• In partnership with clinical department Managers, monitor patients for outlier and disability status and coordinates actions that will reduce the Plan’s liability.
• Evaluating data to report trends, variants and standard deviation from the mean, as in identifying providers and practitioners who may be over or under-utilizing services for our members. Identify membership demographics where over and underutilization may exist and drive down into community interventions to improve outcomes.
• Provide support to the Senior Medical Director and prepare monthly agenda topics and materials for the UM Workgroup/Committee.
• Take recommendations from the UM Workgroup/Committee to the UM/DM/QM Provider Advisory Committee for approval.
• In partnership with clinical department Managers and inpatient coordinators, collaborates to develop and implement an integrated and individualized care plan for members, as needed.
• Provide support to the Senior Medical Director and prepare monthly agenda topics and materials for the UM Workgroup/Committee.
• Take recommendations from the UM Workgroup/Committee to the UM/DM/QM Provider Advisory Committee for approval.
• Collect UM information and uses it for performance improvement and QI activities/initiatives as required by the UM/QI programs
• Assist in the oversight of any delegated UM arrangements if any such arrangements exist
• Work with the QI department to facilitate the annual review and approval of MCG criteria
• Ensure adequate and timely care through clinical review of documentation, document preparation and maintenance which enables prompt response to claim submittal, regulatory agency audits and surveys and other internal and external requests for data
• Implement, monitor and evaluate the Provider Gold Card auditing and review process, providing monthly reports on performance to the appropriate executives and committees.
• Participate in all contractual and regulatory audits involving the department, and to lead the department/staff in the audit preparations
• Participate in the Quality Improvement process to ensure that quality care and services are provided to the member in a timely manner. This includes the identification and referral of quality sentinel events identified during the provision of medical services including an inpatient confinement to the QI department for investigation
• Implement, track, communicate and report department monthly auditing process for adherence to regulation, policy, procedures and staff performance i.e. accuracy and quality.
• Conduct 1:1 meeting with direct reports monthly to provide feedback on employee performance, mentoring and development plans.

• Provide direction/guidance and training to plan staff and providers, as needed.
• Provide management and supervision to the department by:
  1. Interviewing potential new hires, along with the department Lead, when staff vacancies occur
  2. Hiring/disciplinary actions/terminating
  3. Ensuring that effective orientation of new hires to position and training for job function, including new hire training tracking and periodic documented re-training of all department staff is implemented by the department Supervisor
  4. Timely staff job performance review (JPR)
  5. Salary & bonus determinations
  6. Keeping Job Descriptions up to date
  7. Scheduling staff including approving PTO requests, signing timesheets, and approving overtime
• Establish atmosphere of compliance with requirements within the department
  1. Being aware and knowledgeable of key requirements (contractual, regulatory, accreditation) related to departmental and pertinent interdepartmental activities, and the reference materials supporting these
  2. Ensure all P&Ps required are kept up to date, accurate and meeting requirements through annual review
  3. Both for staff performance and core department functions, establish departmental performance measures and standards and develop performance monitoring tools/reports to allow for effective performance tracking and comparisons over time. Institute corrections for identified deficiencies, as necessary
  4. Achieve department goals related to organizational priorities, contractual requirements or other established benchmarks
• With the Medical Director and department clinical staff, assures that additional factors and complications of member care are addressed if not covered in MQD criteria such as: age; co-morbidities; complications; progress of treatment; psychosocial situation, and home environment, when applicable. Assures that additional complications for member care are addressed on an individual basis such as:

1. Ensure availability, appropriateness, payment and process to cover Medical or Specialty/Shelter Respite beds when a safe and suitable option for member’s condition who may be houseless and recovering from a recent hospital stay.
2. Ensure viability of skilled nursing facilities, sub-acute care facilities or same level of care provided in hospital if facilities are not available in the community
3. Works with case management to ensure availability of home care in the urban and rural service areas to support the patient after hospital discharge
4. Local hospitals' ability to provide all recommended services within the estimated length of stay.

• Identify interdepartmental and organizational interdependencies
  1. Ensure smooth execution of key interdependencies (organizationally and departmental)
  2. Timely and accurate submission of quarterly State regulatory reports

• Ensure that continuing education needs of clinical and paraprofessional staff are in place
• Prepare budgets and monthly variance explanations
• Sign off on check requests for departmental expenditures
• Hold departmental meetings documented with minutes – including sharing non-confidential items of interests from Managers’ Meetings
• Participate in Managers meetings
• Participate in organizational workgroups or assigning other departmental staff to participate, as appropriate
• Perform administrative duties of the department Supervisor during absences or vacancies
• Responsible to maintain AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title

Required Competencies and Qualifications:

• Licensed RN in the State of Hawaii
• A minimum of five (5) years of recent managed care, case management, utilization review, authorization process experience required
• A minimum of two (2) years of management experience
• Strong ability to function independently and coordinate the work of other personnel effectively.
• Must be able to work as a team
• Must exhibit strong clinical, planning, organizational and time management skills
• Basic computer knowledge
• Must be able to communicate clearly (verbal and written) across departments and to providers to facilitate action plans.
• Strong planning, organization and time management skills required.
• Intermediate computer knowledge.
• Must communicate with internal and external staff in a professional manner
• Learn and develop experience in the use of AlohaCare’s information system, proprietary screening tool, care management system, QNXT and, as necessary, AlohaCare’s historical databases
• Ability to conduct training with audiovisual presentations.

Preferred Qualifications

• Three years inpatient clinical experience
• State regulatory experience
• URAC/NCQA and HEDIS exposure an asset
• Familiarity with Federal and State Medicaid regulations, national accreditation standards, and HEDIS.

Additional Job Requirements:

• Able to travel within area and occasionally out of area.
• Ability to use Utilization Management software, MCG Criteria, Microsoft Office, CPT and ICD-10 Manuals, AlohaCare Policy and Procedure

Physical Demands/Working Conditions:

• May require prolonged sitting- up to 4 hours
• Requires operation of a computer workstation, including keyboard and video display terminal.
• Ability to communicate via telephone and within a group
• May require occasional lifting, up to 20 pounds.
• Requires verbal and written communication in English with members and providers
• Requires access to own transportation if needed to attend off-site meetings.

Salary Range: $100,000 - $110,000 annually

AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veterans’ status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.