At Alameda Alliance for Health (Alliance) we are striving each day to create a healthier community and to improve the quality of life of our members throughout our diverse County. As a part of our mission, we collaborate with our provider partners to address social determinants of health and to deliver high quality, accessible, and affordable health care services.
The Clinical Supervisor, Outpatient Utilization Management (UM), under the direction and supervision of the Manager, Outpatient UM, is responsible for monitoring and supervising the daily activities of clinical staff performing prior authorization activities and Out of Plan Services (CBAS, CCS). Works closely with Non-Clinical Supervisor to ensure completion of daily UM activities of staff.Principal responsibilities include:
- Supervise daily activities of staff including distribution of workload.
- Daily auditing of clinical staff reviews for appropriateness.
- Conduct daily huddles with clinical team.
- Monitor daily production goals. Identify root cause for any productions issue. Implement changes as necessary and monitor outcomes.
- Create and refine departmental documentation, including standards and procedures, guidelines, workflows, and other relevant records. Responsible for the timely revisions, maintenance, and storage of such documentation.
- Analyze operational and production reports on a daily, monthly and quarterly basis. Identify trends, root causes and mitigation. Review with Manager weekly.
- Trouble shoot issues and implement solutions to ensure successful claims adjudication.
- Respond to and interpret Alliance protocols and guidelines for authorizations.
- Assure compliance with all payer contracts and delegated network Division of Financial Responsibility (DOFRs) as related to prior authorization rules.
- Assure departmental compliance with Medi-Cal, CMS, NCQA, as well as all county, state, and federal regulations and mandates.
- Interface with and advise management on opportunities to improve efficiency of the prior authorization process.
- Serve as Outpatient Clinical UM “subject matter expert” to Alliance. Conduct necessary research and subsequent training on relevant and current issues in the industry.
- Actively participate in intradepartmental management team meetings. Frequently strategize with others in UM, Pharmacy, G & A, and Health Education to ensure overall optimal performance of the Health Plan Services department.
- Act as the liaison between other internal departments including, but not limited to Provider Relations, Member Services, Claims, Case and Disease Management, I.T., Compliance, etc.
- Serve as the liaison between Alliance and outside organizations including, but not limited to hospitals, vendors, and delegated medical groups to help resolve situations with authorizations, eligibility, and claims.
- Actively participate in recruitment, hiring, and training of clinical staff.
- Develop and communicate staff performance plans as well as conduct annual performance appraisals with OP UM Manager.
- Stand in for OP UM Manager and/or Non-Clinical Supervisor as required.
- Prep reports for Utilization Management Committee as directed.
- Assists Manager with DHCS, NCQA and DMHC audit prep.
- Works closely with UM Medical Director as required.
- Maintain daily case load.
- Participate in strategic and departmental goal planning with Manager.
- Complete other duties and special projects as assigned.
ESSENTIAL FUNCTIONS OF THE JOB
- Hire, supervise, and train staff.
- Perform writing, administration, analysis, and report preparation.
- Problem identification and resolution.
- Participate in audit activities.
- Excellent verbal and written communication skills.
- Lead and participate in internal and external committees and meetings.
- Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
EDUCATION OR TRAINING EQUIVALENT TO:
- Constant and close visual work at desk or computer.
- Constant sitting and working at desk.
- Constant data entry using keyboard and/or mouse.
- Constant use of telephone headset.
- Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
- Frequent lifting of folders and objects weighing between 0 and 30 lbs.
- Frequent walking and standing.
- Occasional driving of automobiles.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
- California licensed Registered Nurse.
- Bachelor of Science in Nursing from an accredited college.
- Certification in Health Administration a plus.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
- 3 -5 years of Managed Care Experience required in either a Health Plan or IPA setting.
- Direct experience with MediCal population required; Medicare and Commercial working knowledge a plus.
- Minimum of 3 years of Supervisor experience in a healthcare environment required; management in Managed Care setting preferred.
- Minimum three years customer service experience in the health care field (preferably in a health plan setting.
- Proficient in medical terminology and CPT, ICD10-CM, HPCS codes.
- Excellent verbal communication skills and effective written communications skills required.
- Proven experience in writing and implement policies and procedures.
- Ability to motivate and train staff.
- Well organized and detail oriented.
- Ability to handle multiple projects and balance competing priorities and short deadlines.
- Demonstrated skills in problem resolution.
- Independent thinker, logical.
- Skilled proficiency in the use of computer software including Windows and current Microsoft Office suite required.
$89,360 - $134,050/annually
Alameda Alliance for Health is an EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.