1.0 FTE Full time Day – 08 Hour R2334081 Remote 86242 PI-POPULATION HEALTH-HPO Nursing 180 El Camino Real,PALO ALTO,California
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Day – 08 Hour (United States of America)This is a Stanford Health Care job.
A Brief Overview
Under the supervision of the Senior Director of Accountable Care Management, the Manager-Nursing Utilization Management is responsible for the overall functions of concurrent review and prior authorization for the accountable care population. This role is accountable for performance outcomes and assuring efficient day to day operations.
Stanford Health Care
What you will do
- The essential functins listed are typical examples f wrk perfrmed by psitins in this jb classificatin, and are nt designed t cntain r be interpreted as a cmprehensive inventry f all duties, tasks, and respnsibilities. Specific duties and respnsibilities may vary depending n department r prgram needs withut changing the general nature and scpe f the jb r level f respnsibility. Emplyees may als perfrm ther duties as assigned.
- Supervisry duties:
- Respnsible fr hiring, traiing, and supervisin f clinical and nn-clinical staff
- Mnitr and supprt daily peratins and wrkflw issues accrding t established plicies and prcedures
- Develp and cmmunicate staff perfrmance plans. Cnduct annual perfrmance appraisals. Implement crrective measures as necessary.
- Supervise functinal develpment f plicies and prcedures related t clinical peratins, and ensure crdinatin acrss departments while maintaining cmpliance with federal and state regulatins.
- Assist with the develpment, implementatin, and versight f the utilizatin management prgram, the UM/QI wrkplans, and ther reprts and presentatins as assisgned.
- Assist with the develpment and maintenance f the departmental budget
- Assist with crdinatin f issues related t UM decisin-making fr the Medical Directr and Netwrk Management
- Assist in the preparatin f identified quality f care issues fr the referral t peer review.
- Ensure all delegated case managment dunctins are being perfrmed with cmpliance t regulatry, medical grup, and health plan standards.
- Assist with pre-cntractual and annual due diligence fr audits with health plans.
- Wrkflw Imprvement:
- Cllabrates with Custmer Service and Claims peratins and ther departments t ensure interdepartmental wrkflws remain effective.
- Prvides direct interface with Health Plan versight Auditrs as needed and prvides versight t the preparatin f rutine health plan reprts.
- Accuntable fr the develpment, review and testing f authrizatin rules with in the accuntable care cntract systems.
- Crdinate timely respnses and reslutins t member appeals and grievances.
- Identify current reference surces fr nging clinical peratins issues and prvide rutine staff develpment frums.
- All ther duties as assigned including department-specific functins and respnsibilities
- Perfrms ther duties as assigned and participates in rganizatin prjects as assigned.
- Adheres t all safety, HIPAA and cmpliance plicies.
- Bachelor’s degree
- • Five plus (5+) years in a managed care setting (I.e. HMO, IPA, or medical group) • Three plus (3+) years in a managerial role
Required Knowledge, Skills and Abilities
- Strong understanding of the managed care environment, and knowledge of healthcare benefits associated with various business lines (Medicare,Commercial, etc.)
- Knowledge of the Nurse Practice Act, California Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services (CMS), NCQA, HIPPA, ERISA, EMTALA and all other applicable federal/state/local laws and regulations.
- Strong verbal/written communcation and listening skills. Excellent interpersonal skills and telephone communication.
- Strong clinical judgement necessary to interpret and follow medical guidelines in authorizing services or making referrals to the Chief Medical Officer.
- Proficiency in computer operations and comfortable with internet-based applications including fundamental word processing and internet navigation skills.
- Ability to effectively organize and prioritize tasks in order to complete assignments within the time allotted and maintain standard workflow.
- Ability to work with others in a flexible, cooperative manner. Ability to maintain composure during challenging interpersonal interactions.
Licenses and Certifications
- Nursing\RN – Registered Nurse – State Licensure And/Or Compact State Licensure .
These principles apply to ALL employees:
SHC Commitment to Providing an Exceptional Patient & Family Experience
Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.
You will do this by executing against our three experience pillars, from the patient and family’s perspective:
- Know Me: Anticipate my needs and status to deliver effective care
- Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
- Coordinate for Me: Own the complexity of my care through coordination
Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.
Base Pay Scale: Generally starting at $83.89 – $111.16 per hour
The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.
Saving Lives and Changing the Future of Medicine
Stanford is a part of the top 10 highest ranked Level 1 Trauma Magnet Facilities in the U.S. Combining clinical care, research, and education, our team provides compassionate, coordinated and personalized care for the unique needs of every patient. As the only Level I trauma center between San Francisco and San Jose, Stanford Health Care delivers clinical innovation across its inpatient services, specialty health centers, physician offices, virtual care offerings and health plan programs. With a state-of-the-art hospital, more than 2,800 medical staff and more than 1,300 residents and fellows, Stanford Health Care is committed to making a lasting impact through research, education and clinical care.
Stanford offers exceptional benefits and competitive pay to ensure our staff feels supported in and outside of their work. Specific roles are eligible for shift differential pay, sign-on/relocation bonus, etc. For more information, please visit our Total Rewards page!
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