What are the responsibilities and job description for the Manager, Utilization Review - Care Coordination Admin - Full Time 8 Hour Days (Exempt) (Non-Union) position at University of Southern California?
The Manager of Utilization Review provides administrative and operational support to the Director of Case Management. The Manager of Utilization Review provides direct supervision to the Utilization Review Specialists, Utilization Management Specialists, Authorization Coordinators, and ancillary staff. The Manager provides staff support regarding difficult / complex cases. The Manager is accountable for daily department operations, including establishing utilization review processes that conform to evidence-based review expectations, payer expectations, support collaboration with organization's billing partners, and appeal processes. This position is responsible for daily team operations, including staffing, assignments, and human resources management.
Essential Duties :
- Leadership & Supervision : Manage and mentor a team of RN Utilization Review Specialists, LVN Utilization Management Specialists, Authorization Coordinators, and ancillary staff. Provide guidance and support in the development of staff skills and competencies, including but not limited to orienting, training, daily staffing and staff assignments. Conduct performance evaluations and implement development plans for team members. Engage in special projects, research, consultation and teaching in areas of specialty as needed by the hospital. Provide leadership in quality management and improvement activities, by planning, organizing, coordinating, monitoring and evaluating care and activities provided by personnel.
- Clinical Review Oversight : Supervise the clinical review process to ensure reviews are conducted accurately and in line with evidence-based guidelines.
- Develop and implement standards and processes for clinical and non-clinical services provided by Utilization Review team members, including provides organizational planning and program development for needed services. Utilizes advanced theoretical knowledge and skills to act as consultant to the staff and to the administrative team. Collaborate with clinical teams within Care Coordination to resolve complex cases and ensure authorizations of appropriate care levels. Formulates and implements policies and procedures related to areas of management, and provides feedback and statistics to hospital administration regarding areas of oversight. Maintains competencies for hospital, age specific and job specific standards of care, follows hospital procedures for accurate and timely processing of charges.
- Appeals Management : Develop and implements standards and processes for the formulation and submission of appeal requests for denied services, ensuring they are complete, accurate, and submitted in a timely manner. Analyze trends in denied claims and collaborate with internal and external partners to address and rectify identified issues.
- Regulatory Compliance : Ensure that all processes comply with relevant healthcare regulations, accreditation standards, and organizational policies. Stay updated on industry standards and changes in regulations to maintain compliance. Legal and ethical standards - to be incorporated into all aspect of Utilization Review processes.
- Process Improvement : Identify and implement process improvements to enhance the efficiency, effectiveness, and outcomes of the Utilization Review team. Develop and maintain departmental policies and procedures. Participate in the development, monitoring and analysis of process and outcome indicators for the improvement of patient care.
- Reporting and Analytics : Generate and analyze reports related to utilization review activities and appeal outcomes. Use data to drive decision-making and to identify opportunities for improvement. Prepare and present reports reflective of utilization review activities and appeal outcomes to department meetings, UM Committee meetings, and other committee meetings upon request.
- Performs other duties as assigned.
Required Qualifications :
Preferred Qualifications :
Required Licenses / Certifications :
Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)
The annual base salary range for this position is $110,240.00 - $181,896.00. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education / training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.
USC is a smoke-free environment
USC is an equal opportunity, affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, disability, or any other characteristic protected by law or USC policy. USC will con sider for employment all qualified applicants with criminal records in a manner consistent with applicable laws and regulations, including the Los Angeles County Fair Chance Ordinance for employers and the Fair Chance Initiative for Hiring Ordinance, and with due consideration for patient and student safety. Please refer to the Background Screening Policy Appendix D for specific employment screen implications for the position for which you are applying.
We provide reasonable accommodations to applicants and employees with disabilities. Applicants with questions about access or requiring a reasonable accommodation for any part of the application or hiring process should contact USC Human Resources by phone at (213) 821-8100, or by email at uschr@usc.edu. Inquiries will be treated as confidential to the extent permitted by law.
If you are a current USC employee, please apply to this USC job posting in Workday by copying and pasting this link into your browser :
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Salary : $110,240 - $181,896
