At MemorialCare Health System, we believe in providing extraordinary healthcare to our communities and an exceptional working environment for our employees. MemorialCare stands for excellence in Healthcare. Across our family of medical centers and physician groups, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation and teamwork.
The position is responsible for establishing, maintaining and continuously improving Seaside Health Plan processes required to achieve the defined scopes of care coordination and utilization management as well as direct management, training and competency of care coordination and utilization management staff.
Responsible for the operational execution of the Utilization Management Program under the Director of Operations and the Chief Medical Office.
* Responsible for the development, implementation, and evaluation of the Utilization Management Program and Work Plan and reports Quality Management activities to the Chief Medical Officer, Utilization Management Committee and the Quality Council.
* Responsible for the operations and management staff assigned to all Utilization Management, Case Management, and Care Coordination activities for Seaside Health Plan, including monitoring and reporting as required by regulation or contract.
* Responsible for managing the Utilization Management staff which may include, but not limited to the following positions: Utilization Review Coordinator, Utilization Management Nurse, Case Management Coordinator, HMO Coordinator, and Utilization Management Clerk. Sign a Separation of Medical Services from Fiscal and Administrative Management Acknowledgement at least every 2 years.
Formalize care coordination and utilization management processes, roles, responsibilities, policy and procedures and job descriptions and continuously update documents as improvements are implemented. The Director of Care Coordination is also responsible for ensuring the development and implementation of policies and procedures related to the functions and duties of Care Coordinators; participates in utilization review activities and serves as a quality improvement team member.
Develop modules and conduct orientation/ training for all aspects scope and responsibilities always with a focus on compliance and patient and family centered care and cultural diversity. Training is required to be ongoing and updated as improvements in processes are implemented. Training/orientation includes but is not limited to: interdisciplinary care plan tools and protocols, family support plans, referral processes, case management, monitoring, follow up, transition planning, health education; palliative care, concurrent and retroactive authorization processes, eligibility and benefits, guidelines and community standards for care, clinical trial coordination.
Documentation and Tools
Develop or adapt documentation, tools and procedures for all aspects of care coordination and utilization management scope and responsibilities.
Assessment and Continuous Improvement:
Develop or adapt standardized assessment tools that the Utilization Management Committee, care coordination and utilization management can use to monitor results and promote improvements in care coordination, utilization management, patient and family centered care and cultural diversity. On a quarterly basis, provide a formalized, data driven, written report to the Administrative Team that reviews assessment information and continuous performance improvement processes that address the assessment results. Provide data per UM Plan and as required per contractual and internal standards.