Job Description

Description

SHIFT: Work From Home
SCHEDULE: Full-time

Do you have the career opportunities you want in your current role? We have an exciting opportunity for you to join the nation's largest provider of healthcare services as a Nurse Utilization Management Manager.

HCA Healthcare is a national leader in providing modern, culturally competent, patient-centered care and we are driven by a single goal: the care and improvement of human life.

We offer you an excellent total compensation package, including competitive salary, excellent benefit package and growth opportunities. We believe in our team and your ability to do excellent work with us. Your benefits include 401k, PTO medical, dental, flex spending, life, disability, tuition reimbursement, student loan repayment, employee discount program, employee stock purchase program. We would love to talk to you about this fantastic opportunity.

The HCA Physician Services Group (PSG) is the physician and practice management solution for the Hospital Corporation of America (HCA). We lead a collection of highly motivated healthcare professionals just like you and creative leaders who are committed to excellence in every patient interaction. Are you excited yet?

Pacific Partners Management Services (PPMSI) is a managed services organization formed in 1997, located in the heart of the Silicon Valley in Campbell, CA. We provide services to IPAs in the Santa Clara and Monterey Bay areas. Our managed care and ACO services support approximately 1,000 independent physicians and include executive management, full financial services, utilization management, quality improvement, credentialing, contracting, claims processing and provider and member network services.

PPMSI is part of HCA Physician Services Group (PSG), the physician and practice management solution for the Hospital Corporation of America (HCA). PSG operates more than 750 practices, Urgent Care Facilities, and partners with HCAs 165 hospitals to structure employed provider programs, professional service agreements, and joint ventures that offer the communities we serve high quality, cost effective care. We manage a collection of highly motivated and innovative leaders who are committed to excellence in every aspect of their career.

Click here to learn more

This position is a work from home (WFH) position but the candidate must be located in the San Jose, CA area.

What you will do in this role:

The Utilization Management (UM) Managers primary function is to ensure timely review of referral requests, procedure, and pre-certification requests in accordance with established policy.

DUTIES AND ESSENTIAL JOB FUNCTIONS

1. Document department policies and procedures in coordination with the Medical Director and CMO revising procedures as necessary.
2. Assist with compiling training manuals, training staff and revise training manuals as necessary.
3. Oversee preauthorization of managed care services. Ensure that notification of approvals/denials for services meet HMO and regulatory contractual guidelines.
4. Interview, hire, train, and discipline direct reports and supervise department staff.
5. Document, conduct, and/or review employee performance appraisals.
6. Maintain accurate individual performance records and manage actual performance to meet expected performance levels
7. Perform quality audits on responses to authorizations received telephonically and electronically.
8. Contact providers and/or provider office staff to request additional medical information, as required evaluating complex authorization requests.
9. Coordinate patient care information with utilization management, concurrent review nurses and case managers.
10. Collect and report risk management and potential quality of care events to Medical Director and QI.
11. Serve as liaison with health plans and providers for complex or sensitive member issues.
12. Working knowledge of all regulatory requirements, i.e. NCQA, HEDIS, CMS and required reporting.
13. Responsible to manage health plan audits and reporting for UM and Medical Management related requirements.
14. Inform Medical Director of system and operational issues and serve as a member of the Management Team.
15. Maintain departmental performance standards.
16. Understand and effectively manage electronic and non-electronic referral systems.
17. Implement UM manual policies and procedures.
18. Promotes a cooperative relationship between the HMOs, Providers, Employer Groups and other departments of PPMSI.
19. Work with Utilization Management and Quality Improvement, Utilization Review, and Health Plan Compliance to ensure that information concerning managed care is disseminated to appropriate internal and external entities.
20. Balance numerous priorities while being creative and results oriented
21. Assign staff and supervise work to ensure efficient operation and compliance with standard processes and special projects.
22. Monitor and Coordinate Health Plan Compliance.
23. Lead, coordinate, and prepare meeting documentation and reports for UM/QI committee meetings.
24. Perform any additional tasks as assigned by the Medical Director/CMO.

Qualifications

What Qualifications you will need:

REQUIRED

1. Must have a nursing degree from an accredited college or university.
2. At least 5 years experience in utilization review or case management within managed care or equivalent experience.
3. Ideally supervisory experience in a clinical or administrative setting.
4. Proficiency with computers, Outlook, Word, Excel and the Internet.
5. Excellent written and verbal communication and presentation skills.
6. Ability to maintain confidentiality.
7. Ability to travel to medical offices as needed.

REQUIRED LICENSES/CERTIFICATIONS

Current unrestricted R.N or L.V.N. license.

Current and valid California drivers license.

HCA Healthcare ranks on Fortunes list of Most Admired Companies for three consecutive years and HCA ranks 63rd on the Fortune 500 list. In addition, Ethisphere named HCA as one of the Worlds Most Ethical Companies. We want you to join our tradition of excellence. Intrigued? Wed love to hear from you.

If you find this opportunity compelling, we encourage you to apply. We promptly review all applications. If you are highly qualified, you will hear from one of our Practice Managers. We are actively interviewing so apply today.

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.

Notice

Our Companys recruiters are here to help unlock the next possibility within your career and we take your candidate experience very seriously. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Gmail or Yahoo Mail. If you feel suspicious of a job posting or job-related email, let us know by clicking here.

For questions about your job application or this site please contact HCAhrAnswers at 1-844-422-5627 option 1.



Register Now