Utilization Review Manager

  • Contra Costa County, CA
  • Martinez, California
  • Mar 07, 2019
Full Time Administration and Management Public Health
  • Salary: $141,683.77 - $172,217.52 Annually

Job Description

The Position

OPEN UNTIL FILLED

Bargaining Unit: Local 21 - Supervisory Management

The Contra Costa County Health Services Department is seeking an individual to fill one vacant Utilization Review Manager position in the Contra Costa Health Plan (CCHP) Department located in Martinez, CA.

The Utilization Review Manager plans, organizes and supervises the activities of the unit staff; prepares department for internal and external audits; conducts utilization management delegation audits and develops policies and procedures for adherence to governmental and accredited agency standard. The successful candidate will oversee and participate in the development and implementation of effective and efficient standards, policies, protocols, processes, reports and benchmarks that support and further enhance utilization management and timely access to care.

The ideal candidate will have a proven track record demonstrating the following:
  • Strong management and problem solving skills
  • Excellent interpersonal skills
  • Skilled at internal and external audits

Characteristics of the ideal candidate:
  • Knowledgeable and experienced in utilization management and review
  • Ability to respond effectively to appeals
  • Seasoned supervisory RN in managed care as a Utilization Review Nurse, Discharge Planner or Case Management Nurse

Read the complete job description at https://www.cccounty.us/hr . The eligible list established from this examination may remain in effect for six months.

TENTATIVE EXAM DATE
Training and Experience Evaluation: Periodically

Typical Tasks
  • Supervises and trains subordinate staff in methods and practices pertinent to their assignments
  • Confers with subordinates regarding dispositions of problems
  • Interviews, selects, hires, orients, evaluates, counsels and recommends discipline of subordinate staff
  • Reviews and analyzes governmental and accrediting agency standards governing admissions, treatment and continued stay of patients to develop policies and procedures
  • Reviews patient treatment plans to ensure adherence to established criteria and standards
  • Assists review committee in planning and holding federally mandated utilization reviews, periodic medical reviews and professional reviews


When Assigned to Contra Costa Regional Medical Center:


  • Refers cases to Utilization Review Committee for review and course of action when case fails to meet criteria
  • Analyzes individual patient records to determine validity of admission
  • Serves as review committee liaison with other hospital committee in development of policies and procedures
  • Supervises and coordinates activities of utilization review staff in maintenance of informed policy and procedure manuals, files, records and correspondence
  • Keeps informed of patient disease processes and treatment modalities through reading clinical literature


When Assigned to Contra Costa Health Plan:


  • Oversees and participates in the development and implementation of effective and efficient standards, policies, protocols, processes, reports and benchmarks that support and further enhance utilization management and timely access to care
  • Provide guidance on issues related to referral and authorization process, benefits interpretation, and other utilization issues
  • Prepare department for internal and external audits, NCQA accreditation, and conduct utilization management delegation audits
  • Accountable for the oversight of delegated entities' utilization management and access to care; performs annual oversight audits


When Assigned to the Behavioral Health Division:


  • Develops and implements Utilization Review standards, policies, protocols, and processes to ensure Contra Costa Mental Health Plan (CCMHP) compliance
  • Evaluates and supervises the response to first level appeals for denial of services to inpatient psychiatric services and claims to the Institution of Mental Diseases (IMD)
  • Organizes and participates in audits by California Department of Health Care Services (DHCS), External Quality Review Organization (ERQO) and federal agencies including Office of the Inspector General; ensuring the county meets the required standards for compliance, avoidance of disallowance and maintenance of county certification
  • Provides guidance on authorization process, benefits interpretation, and critical time lines to Community Base Organizations (CBOs) and
    County operated clinics; in addition ensuring they meet requirements and are in compliance according to Utilization Management and Utilization Review process
  • Develops and manages of Utilization Management and Review Plan through the implementation of California State Substance Use Disorder (SUD) waiver program within the Behavioral Health Division's Alcohol and other Drug Services and Mental Health programs.

Minimum Qualifications

License Required: Candidates must possess and maintain throughout the duration of employment: a current, valid and unrestricted license as a Registered Nurse issued by the California Board of Registered Nursing.

Education: Possession of a bachelor's degree in nursing from an accredited college or university.

Experience for Contra Costa Health Plan Assignment: Three (3) years of full-time, or its equivalent, experience as a Registered Nurse in a managed care organization (i.e. HMO), two (2) years of which must have included experience as a Utilization Review Nurse, Discharge Planner, or Case Management Nurse, one (1) year of which must have been in a supervisory capacity.
Experience for Contra Costa Regional Medical Center Assignment: Three (3) years of full-time, or its equivalent, experience as a Registered Nurse in an acute care hospital or hospital based ambulatory care health center, two (2) years of which must have included experience as a Utilization Review Nurse, Discharge Planner, or Case Manager Nurse, one (1) year of which was in the capacity of a Charge Nurse, Supervisor or Lead Nurse.

Experience for Behavioral Health Division Assignment: Three (3) years of full-time, or its equivalent, experience as a Registered Nurse in a behavioral health organization (i.e. Mental Health Outpatient Clinic or Inpatient or Emergency Psychiatric Facility), two (2) years of which must have included experience as a Utilization Review Nurse, Discharge Planner, or Case Management Nurse, one (1) year of supervisory experience.

Substitution for all assignments: Two (2) additional years in a Nurse Supervisor capacity may be substituted for the Bachelor's Degree. A Master's Degree in nursing, hospital or health care administration or closely related field may be substituted for one (1) year of experience as a Registered Nurse. No substitution is allowed for the required one (1) year of supervisory experience.

Other Requirements: A background investigation/fingerprint and/or physical exam may be required prior to the start of employment.

A COMPLETED SUPPLEMENTAL QUESTIONNAIRE IS REQUIRED. AN APPLICATION SUBMITTED WITHOUT THE SUPPLEMENTAL QUESTIONNAIRE WILL BE CONSIDERED INCOMPLETE AND WILL THEREFORE BE DISQUALIFIED.

Selection Process
1. Application Filing: All applicants must apply on-line at www.cccounty.us/hr and submit the information as indicated on the job announcement by the final filing date. A completed supplemental questionnaire is required at the time of applying.

2. Application Evaluation: Depending on the number of applications received, an Application Evaluation Board may be convened to evaluate and select the best-qualified candidates for invitation to the next phase of the examination.

3. Training and Experience Evaluation: Consists of an evaluation of each candidate's relevant education, training and/or experience as presented on the application and supplemental questionnaire. (Weighted 100%)

4. Candidates must receive a score of at least 70, which may be an adjusted score, in order to be ranked on the employment list.

The Human Resources Department may change the examination steps noted above in accordance with the Personnel Management Regulations and accepted selection practices.

CONVICTION HISTORY
After you receive a conditional job offer, you will be fingerprinted, and your fingerprints will be sent to the California Department of Justice (DOJ) and the Federal Bureau of Investigation (FBI). The resulting report of your conviction history (if any) will be used to determine whether the nature of your conviction conflicts with the specific duties and responsibilities of the job for which you have received a conditional job offer. If a conflict exists, you will be asked to present any evidence of rehabilitation that may mitigate the conflict, except when federal or state regulations bar employment in specific circumstances. Having a conviction history does not automatically preclude you from a job with Contra Costa County. If you accept a conditional job offer, the Human Resources department will contact you to schedule a fingerprinting appointment.

DISASTER SERVICE WORKER
All Contra Costa County employees are designated Disaster Service Workers through state and local law. Employment with the County requires the affirmation of a loyalty oath to this effect. Employees are required to complete all Disaster Service Worker-related training as assigned, and to return to work as ordered in the event of an emergency.

EQUAL EMPLOYMENT OPPORTUNITY
It is the policy of Contra Costa County to consider all applicants for employment without regard to race, color, religion, sex, national origin, ethnicity, age, disability, sexual orientation, gender, gender identify, gender expression, marital status, ancestry, medical condition, genetic information, military or veteran status, or other protected category under the law.