Job Abstract

Under direction, to organize, direct, and supervise the Utilization Review functions as required by Federal and State regulations and the Valley Health Plan (VHP) Utilization Review department.

The Utilization Review Supervisor – VHP position provides effective leadership, develops and implements solutions to address efficiency and compliance issues, and optimizes workflow and operations within the Utilization Management unit. The ideal candidate will have strong knowledge of Federal and State health care laws and regulations common to the operation of hospitals in California as well as innovative thinking, strong analytical skills, root cause analysis, and application of evidence-based clinical guidelines. In addition, this position will be expected to work collaboratively with VHP’s physician leadership and apply critical thinking to make decisions on covered medically necessary services.

The following is a descriptive list of the range of duties performed by employees in this classification and is not intended to reflect all duties performed by every incumbent in this classification:

• Directs, evaluates, and develops systems and procedures to meet the goals and objectives of the Utilization Review department for VHP;

• Evaluates the compliance of the Utilization Review functions in terms of state-mandated standards and regulations, and offers solutions and efficiencies to improve compliance with required regulations;

• Supervises, directs, trains, and evaluates utilization review staff, which is comprised of clinical and non-clinical team members;

• Prepares work schedules and makes assignments;

• Attends meetings as required;

• Evaluates Utilization Review policies and procedures and makes recommendations regarding such;

• Prepares and submits reports as required;

• Acts as a technical resource for VHP staff as it relates to Utilization Review;

• May be assigned as a Disaster Service Worker, as required;

• other related duties, as required.

Sufficient education, training, and experience to demonstrate the possession and direct application of the following knowledge and abilities:

Experience Note:The required knowledge and abilities are attained through possession of an Associate’s Degree in Nursing, Health Care Administration, or a related field,

• Possess and maintain a valid California Registered Nurse License.

• Possession of a Utilization or Case Management certification is highly desired.

• Ability to travel to alternate locations in the course of work. If driving, possession of a valid California driver’s license prior to appointment and the ability to qualify for and maintain a County driver authorization.

• Hospital organization, operations, and procedures;

• Principles of supervision and program management;

• Federal and State health care laws and regulations common to the operation of hospitals in California;

• Regulations of intermediary agencies pertaining to hospital stay coverage (e.g., Medicare/Medi-Cal);

• Medical terminology and related levels of care and treatment;

• Principles and applications of a hospital data processing system as it relates to Utilization Review;

• Policy and procedure development;

• Role of the public teaching hospital;

• Evaluation and assessment techniques.

• Analyze, develop, and implement effective reporting systems and procedures;

• Analyze, interpret, apply, and implement Federal and State rules and regulations;

• Collect and record data;

• Act as a technical resource to physicians and Utilization Review staff;

• Supervise, plan, and assign workload of Utilization Review staff;

• Evaluate data and statistics;

• Work independently to set priorities and make effective decisions;

• Communicate effectively in English, both orally and in writing;

• Establish and maintain effective working relationships with those contacted in the course of work, at all levels, including colleagues, the public, and other agencies.