Job Description

This position reports to the Director of Clinical Services. Under administrative direction is responsible for the overall work product of a Utilization Review team comprised of Utilization Review Nurses and Medical Management Coordinators. The nature of the work involves coaching and counseling, monitoring work performance to assure compliance with company standards and Labor Code rules and regulations, conducting performance evaluations, and instituting corrective action when appropriate.

Essential Duties and Responsibilities:

• Project management using AI tools and office tools.
• Works effectively with peers across departments, demonstrating professionalism, respect, and a team-oriented approach.
• Responsible for overseeing the day to day operations of the UR team for all offices of InterMed.
• Responsible for the timely completion of performance reviews for all personnel within the assigned unit (staff evaluation).
• Provides ongoing advice, mentoring, coaching, counseling and performance feedback to assigned staff (training & development).
• Deals quickly and decisively with personnel issues as they arise. Keeps the supervisor informed with regard to the need for or the progress of any corrective action activities.
• Exhibits a knowledgeable and helpful attitude and projects a professional image on behalf of InterMed and Intercare.
• Performs weekly audits of >10% of reviews per UR Nurse for the purpose of validating accuracy and completeness of the utilization review process.
• Responsible for insisting upon a spirit of teamwork and cooperation between the staff and the personnel of other departments for InterMed and Intercare and other clients.
• Requires a comprehensive knowledge of the Utilization Review guidelines in the Labor Code for the State of California and other states as needed.
• Assist with interviewing, hiring, training, appraising performance, rewarding and disciplining employees, and addressing complaints and resolving problems.
• Oversees training of new staff on computer systems and policy & procedures related to Utilization Review.
• Provides training for Intercare claims team at various locations to ensure timely and accurate work flow.
• Plans, assigns, and directs the work of Utilization Review.
• Determines appropriate caseloads that allow for timeliness of requests and productivity that meets expectations.
• Works with Medical Director to ensure compliance with guidelines for Utilization Review.
• Maintains production performance and savings reports for management review and information.
• Notifies supervisor of potential client issues and works to bring resolution.
• Assists with the implementation of new accounts with input from account management.
• Assists staff in their compliance with client service instructions.
• Authorizes requests for time off to ensure coverage necessary to maintain service guidelines.
• Handles other duties and tasks as deemed appropriate by the Vice President of Managed Care.
• Serves as InterMed’s compliance officer to ensure compliance with state and URAC regulations
• Participate as an active member of InterMed’s Quality Management Program Committee including quarterly meetings to discuss program improvements, measurements, assessments, and compliance.
• Participate in a quality management program meeting and project for at least 40% of average hours worked.
• Maintain awareness of potential compromise in a patient’s safety for each review. Refer to proper authority.

Uses plain language to communicate (written and verbal) with injured workers, claims examiners, and clients.

Requirements

Competency:

To perform the position successfully an individual should demonstrate the following competencies:

• Project Management - Develops project plans; Coordinates projects; Communicates changes and progress; Completes projects on time and budget; Manages team activities.
• Change Management - Develops workable implementation plans; Communicates changes effectively; Builds commitment and overcomes resistance; Prepares and supports those affected by change; Monitors transition and evaluates results.
• Leadership - Exhibits confidence in self and others; Inspires and motivates others to perform well; Effectively influences actions and opinions of others; Inspires respect and trust; Accepts feedback from others; Provides vision and inspiration to peers and subordinates; Gives appropriate recognition to others; Displays passion and optimism; Mobilizes others to fulfill the vision.
• Managing People - Includes staff in planning, decision-making, facilitating and process improvement; Takes responsibility for subordinates' activities; Is available to staff; Provides regular performance feedback; Develops subordinates' skills and encourages growth; Solicits and applies customer feedback (internal and external); Fosters quality focus in others; Improves processes, products and services; Continually works to improve supervisory skills.
• Must be self-motivated with the ability to multi task and adapt to changing work priorities
• Must have strong organizational skills with attention to details
• Must have strong time management skills
• Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Designs work flows and procedures.
• Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations.

Qualification Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience:

Minimum of three years clinical experience. Minimum one year of California Worker’s Compensation Utilization Review experience, including a working knowledge of the California Worker’s Compensation Labor Code and regulations, and other states as needed. Progressive technical experience demonstrating a high degree of judgment and discretion; capable of providing adequate guidance on complex cases.

Language Skills:

Must possess excellent oral and verbal communication and written skills and be able to communicate with internal and external costumers

Math Skills:

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret graphs. Must have skill to calculate procedure costs & billable hours

Computer Skills:

Must be proficient in basic computer skills including Word & Excel

Certificates and Licenses:

Current Unrestricted California RN or LVN License

Supervisory Responsibilities:

Directly supervises employees in the Managed Care Department including UR Coordinators, UR Nurses, and Medical Management Coordinators. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities may include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• While performing the duties of this Job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms and talk or hear.
• The employee will occasionally lift and/or move up to 10 pounds.
• The employee is occasionally required to stand and walk.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.