The Supervisor, Utilization Management (UM) is responsible for daily supervision of the assigned UM staff, oversight of day to day operations in assigned area of responsibility, quality improvement of departmental practices and program development within Population Health. The Supervisor, UM will support the department in a number of ways, to include but not limited to establishing work flows; ensuring appropriate staffing levels and work assignments, and providing coverage as needed; serving as a staff resource on policies and procedures; performing audits on clinical reviews and documentation and supporting the success and growth of the department.
Essential Job Functions:
Supervises assigned UM staff. Establishes UM work flows and reviews Policies and Procedures under the direction of the UM Manager. Serves as a resource for staff. Orients and continuously trains new employees to ensure success in their role and a thorough understanding of the necessary policies, processes and procedures to do their job. Establishes and communicates performance and behavioral standards and follows the appropriate performance improvement and/or disciplinary action when coaching/counseling. Runs daily, weekly, monthly and ad hoc reports to monitor and analyze department performance, assess data against standards and goals, and identifies trends as appropriate. Keeps leadership, staff and physicians informed of updates and changes within the department as appropriate. Collaborates with clinical staff and all levels of personnel as appropriate to assure effective coverage and compliance with Health Plan, CMS, and NCQA requirements. Communicates with and educates MM team as needed regarding UM policies, practices, and procedures to ensure they have the appropriate level of knowledge needed. Identifies and maintains relationships with other departments such as PHM, Claims, PNO, and DMO to facilitate efficient workflows and processes within UM. Supports clinical and non-clinical functions and tasks that impact UM as needed. Assists UM Manager to ensure team strategy objectives are effective expenditures of resources. Regularly and dependably reports to work as scheduled. Follows all MDX Hawai’i policies and procedures, including but not limited to personnel policies, safety policies, and operational policies as communicated by management. Follows all medical management policies and procedures, including, but not limited to procedural guidelines/workflows, attendance requirements, and performance requirements as communicated by management. In accordance with State and/or Federal confidentiality/privacy laws, maintains confidentiality of all company, provider, member, and client information as specified by agilon health. Represents company in a professional manner at all times when dealing with both internal and external customers. Adheres to company HIPAA and Privacy Standards and Confidentiality Agreement and maintains strict confidentiality with regard to all member, provider, and contract services information. Functions as a resource for the department and internal staff, demonstrating a thorough knowledge of all UM policies, procedures and government programs. Promotes professionalism. Performs other duties, as assigned.
- Bachelor’s degree of Science in Nursing (BSN) from a four (4)-year college or university and 2 years- experience in UM or related field; or
- Associate Degree in Nursing (ADN) with a minimum of five (5) years of experience in UM or related field.
- Previous supervisory experience preferred.
- Valid, unrestricted Hawai‘i RN License.