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Utilization Review Manager

Salary: N/A

PUBLIC HEALTH DEPARTMENT SPECIALIZATION

DEFINITION: Under administrative direction, to plan, organize, and manage the utilization review program and related functions; and to perform related duties as required.

EXAMPLES OF DUTIES:

1. Develops and administers polices and procedures for utilization control of inpatient and outside referral services countywide and for in a variety of categorical programs including the Medically Indigent Adult (MIA) Program. Manages the utilization of referral services from a network of seven ambulatory care clinics. Assists in the development and implementation of procedures to track and trend specialty and ancillary service utilization within the clinics.
2. Responsible for monitoring referral patterns and making recommendations to the Medical Director on strategies to contain costs, improve access and insure quality care; and ensures implementation of practice guidelines and referral criteria established by the Medical Director.
3. Responsible for the maintenance of good community relationships with providers who provide services to Public Health Department patients and ensures a responsive system for authorization of services and payment of claims; and assisting in negotiating access to care in targeted areas, as requested.
4. Prepares statistical and narrative reports as requested by administrative staff on utilization patterns, expenditures by area and revenue stream, demographics of service delivery and trending of expenditures by program.
5. Establishes and amends, as necessary, a reporting system for contract providers; monitors and analyzes the use of services from outside providers.
6. Trains professional clinic and program staff on current principals and standards of practice of Utilization Management, medical/surgical diagnosis and treatment coding and reimbursement methodologies.
7. Responsible for the eligibility determination component of the MIA Program, ensuring compliance with Board approved regulations county-wide. Monitors changes in Medi-Cal regulations and proposes related changes in regulations and procedures in the MIA program. Responsible for Medical Social Work and sets expectations for the delivery of social work services countywide.
8. Supervises staff including assigning, reviewing, and evaluating work; interviews and recommends staff to be hired; counsels and disciplines staff; works with staff to develop and implement new and changed systems. Prepares and monitors budgets for programs; develops and reports on performance measures.

EMPLOYMENT STANDARDS: Possession of a valid license as a registered nurse issued by the State of California; and:

1. Two years of experience in utilization review in a hospital or health care setting, including one year of supervisory experience; or,
2. equivalent combination of training, education, and experience that would provide the required knowledge, abilities and license.

Knowledge of: state regulations applicable to treatment and reimbursement under Medi-Cal; utilization review procedures and techniques; medical and surgical diagnoses, procedures and types of treatment; Medical Social Services in ambulatory care; applicable State of California and local Medi-Cal managed care regulations; statistical and fiscal data collection and interpretation.

Ability to: plan, organize and administer Utilization Management programs effectively; supervise others; communicate with others effectively; write clear and concise correspondence using correct grammar, punctuation, and spelling; work with others both within and outside the department; identify medical utilization needs; establish priorities, gather analyze and report data, analyze program regulations and laws governing indigent health care to insure legally compliant program design, ability to communicate effectively orally and in writing, ability to lead change; ability to work effectively with clinics, providers and the community.

ALCOHOL, DRUG & MENTAL HEALTH SERVICES SPECIALIZATION

DEFINITION: Under administrative direction, to plan, organize, and supervise the Mental Health utilization review, and medical social services or medical records functions; and to perform related duties as required.

EXAMPLES OF DUTIES:

1. Directs and supervises the utilization review, and medical social services or medical record functions; develops and administers polices and procedures for utilization control of inpatient and clinic services countywide and for eligibility determination for programs such as the Medically Indigent Adult (MIA), medical social, or mental health services.
2. Trains professional staff on current utilization review techniques and cost containment trends.
3. Supervises staff including assigning, reviewing, and evaluating work; interviews and recommends staff to be hired; counsels and disciplines staff; works with staff to develop and implement new and changed systems.
4. Prepares statistical and narrative reports as requested by administrative staff.
5. Reports periodically on contractual activity to the contracting negotiator; establishes and amends, as necessary, a reporting system for contract providers; monitors and analyzes the use of all medical or mental health services from outside providers.

EMPLOYMENT STANDARDS: Possession of a valid license as a registered nurse issued by the State of California; and:

1. Two years of experience in utilization review in a hospital, health care, or mental health setting, including some supervisory experience; or,
2. one year of experience performing duties equivalent to the class of Utilization Review Coordinator with Santa Barbara County; or,
3. equivalent combination of training, education, and experience that would provide the required knowledge, abilities and license.

Knowledge of: state regulations applicable to treatment and reimbursement under Medi-Cal; utilization review procedures and techniques; medical and surgical diagnoses, procedures and types of treatment; applicable State of California regulations; statistical and fiscal data collection and interpretation; managed care systems in behavioral health organizations, quality and effective indicators for behavioral health care systems; behavioral health services; clinic behavioral health assessment issues and custom treatment interventions; and laws and regulations related to patient rights of the mentally ill.

Ability to: plan, organize, and administer health care or mental health programs effectively; supervise others; communicate with others effectively; write clear and concise correspondence using correct grammar, punctuation, and spelling; work with others both within and outside the department; identify medical utilization needs.
 



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