The Utilization Manager is responsible for all outpatient utilization for Cedars-Sinai Medical Group and Cedars-Sinai Health Associates including daily operations and oversight of the referral department for processing authorizations. Ensures that referral requests are processed according to internal policies which maximize quality and continuity of care while reducing overall costs.In addition, the Manager of Utilization is responsible for ensuring that utilization functions are performed in accordance with internal policies and procedures as well as meeting health plan contractual requirements and regulatory standards. This position manages all staff performing utilization functions for CSHA and CSMG.
ESSENTIAL JOB DUTIES:
- Oversees prospective, concurrent and retrospective review processes and ensures that they are in accordance with industry standards, health plan contracts and regulatory (HCFA, NCQA and DOC) requirements.
- Monitors the utilization of outpatient services and ensures that patients receive high quality care in the most cost effective setting.
- Ensures that all services are provided within the parameters of established contracts and the patient's health plan benefits.
- Reviews outpatient services to identify trends of over and under utilization and reports to Utilization Management and Quality Management Committees as appropriate.
- Ensures that retrospective claims review is performed on a timely basis.
- Oversees all Utilization Management Committee functions and ensures that documentation is per NCQA and health plan standards.
- Participates in investigating and resolving all appeals identified through the QM Department and/or the health plans.
- Ensures that all required reporting to contracted health plans is performed in timely manner.
- Manages all utilization staff.
- Develops policies and procedures for Utilization/Referrals department under guidance of Director, Utilization/Case Management.
- Coordinate and facilitate the yearly Health Plan audit and successfully meet or exceed the standard.
- Works closely with Medical Directors to develop and ensure that referral processing guidelines are communicated to staff and followed accordingly.
- Responsible for training all new staff on referral entry and use of referral system.
- Lead discussions regarding trending of outpatient services.
Since its beginning in 1902, Cedars-Sinai has evolved to meet the healthcare needs of one of the most diverse regions in the nation, continually setting new standards in quality and innovation in patient care, research, teaching and community service.Today, Cedars-Sinai is widely known for its national leadership in transforming healthcare for the benefit of patients.Cedars-Sinai is one of the largest nonprofit academic medical centers in the U.S. with 886 licensed beds, 2,100 physicians, 2,800 nurses and thousands of other healthcare professionals and staff. Clinical programs range from primary care for preventing, diagnosing and treating common conditions to specialized treatments for rare, complex and advanced illnesses. In addition, Cedars-Sinai serves the community through its Medical Network, which includes the highly rated Cedars-Sinai Medical Group and Cedars-Sinai Health AssociatesCedars-Sinai has consistently been named one of America’s Best Hospitals by U.S. News & World Report, has received the National Research Corporation’s Consumer Choice Award 18 years in a row for providing the highest quality medical care in Los Angeles, and has the longest running Magnet designat...ion for nursing excellence in California.Cedars-Sinai is a leader in the clinical care and research of heart disease, cancer and brain disorders, among other areas. Pioneering research achievements include using cardiac stem cells to repair damaged hearts, developing minimally invasive surgical techniques and discovering new types of drugs to target cancer more precisely.Cedars-Sinai also impacts the future of healthcare through education programs that encompass everything from highly competitive medical residency and fellowship programs to a biomedical science and translational medicine PhD program, advanced training for nurses and educational opportunities for allied health professionals. Most notably, Cedars-Sinai demonstrates a longstanding commitment to strengthening the Los Angeles community through wide-ranging programs that improve the health of its most vulnerable residents.