RN Utilization Manager Job at Express Employment Professionals Defunct in Honolu

Express Healthcare is seeking compassionate individuals to support the Utilization Manager position within a community-led, non-profit organization. Employment Type: Full-Time This position is responsible for overseeing day-to-day operations while managing the Utilization Management (UM) program within the Quality Improvement (QI) framework. Core duties include optimizing processes to ensure effective, timely, and cost-efficient care management across medical, behavioral, and community health services. The role involves continuous service monitoring for continuity, necessity, and cost-effectiveness, along with process recommendations to the Director of Medical Management and the Chief Medical Officer. Key Responsibilities: Care Coordination: Work with clinical department managers to oversee members' care levels, ensuring services are aligned with patient needs. Monitor continuity and assess timeliness, cost-effectiveness, and medical necessity. Outlier and Disability Monitoring: Collaborate to identify high-cost or outlier cases, coordinating actions to minimize organizational risk and liability. Data Evaluation and Reporting: Assess data to identify utilization trends, pinpointing overuse or underuse of services. Evaluate member demographics to uncover patterns and design community interventions to improve health outcomes. Committee Support and Recommendations: Support the Senior Medical Director by preparing materials for UM Workgroup/Committee meetings. Relay UM Workgroup recommendations to the Provider Advisory Committee for review and approval. Individualized Care Planning: Partner with clinical managers and inpatient coordinators to create personalized, integrated care plans as needed for individual members. Performance Improvement and QI Initiatives: Gather UM data for use in performance evaluations and QI initiatives to meet program standards. Minimum Requirements: 3-5 years of experience in Utilization Management State of Hawaii RN License Current BLS Certificate Familiarity with Medicaid and Medicare regulations Apply Today: To learn more or for immediate submission, please reply to this ad with an updated resume, or contact us directly at 808-792-7000. #J-18808-Ljbffr