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Providence Director Utilization Management in Anaheim, California



Under the direction of the AVP Non Clinical MSO, this position is responsible for the strategic planning, development, administration and operations of the Utilization Management Programs for the Southern California Region, which includes all networks for Heritage Medical Group and Affiliate Networks. Programs include: Utilization Management (Acute and Ambulatory), Regional Referrals, Government Requirements, and Health Plan Delegation including Workplans, Audits, and Appeals. The position will work closely with each medical director to assure a sound Utilization Management Program.


  • Develops and implements Utilization Programs to ensure that all functions meet internal, Health Plan, and regulatory requirements.

  • Implements, monitors and ensures that Regional Referrals meet provider and patient needs, while maintaining and/or improving utilization metrics.

  • Ensures performance improvement for responsible areas utilizing data, health plan and ministry input.

  • Collaborates with local ministries, Heritage Healthcare Claims, Provider Relations/Membership Services, Contracting and other key departments to ensure areas of accountability and promote organization integration.

  • Ensures staff competency utilizing inter-rater reliability tools and evidence based criteria for utilization review.

  • Establishes excellent working relationships with all internal/external constituents and staff, including all network medical directors.

  • Incorporates system-wide strategic planning in the development of policies and procedures, UM programs and Work Plans.

  • Responsible for the preparation and presentation of materials for all committees and governance as well as changes, trends and concerns related to program compliance and development.

  • Monitors the coordination of the Health Plan audits. Assures that reports and statistics are appropriate and meet the needs of members, physicians, and Health Plans.

  • Develops, monitors, and bears fiscal and operational responsibility for appropriate budgets, including the management and reporting of variances.

  • Ensures that staff possesses the appropriate knowledge and skills necessary to provide case and utilization management appropriate to the age of the patients served including knowledge of the principles of growth and development and psychosocial characteristics and health care needs for all age members of our network.

  • Ensures that staff is competent in assessing and interpreting age appropriate data about the patient’s status in order to identify age-specific needs and provide the care needed.

  • Ensures that staff possesses the appropriate communication skills for the patient population served.

  • Ensures that staff demonstrates knowledge of age-specific community resources.

  • Participates in workgroups that address both clinical and non-clinical activities for which MSO service must demonstrate improvement to meet its contractual requirements with affiliated heal plans, CMS, DHS, DMHC and other applicable entity

  • Manage and respond to corrective action plans (CAPS) for business areas stemming from ongoing monitoring and internal audit activities.


Required experience/education for this position include:

  • Bachelor's Degree in Nursing, or related field

  • Upon request: Driving may be necessary as part of this role. Caregivers are required to comply with all state laws and requirements for driving. Caregivers will be expected to provide proof of driver license and auto insurance upon request. See policy for additional information

  • 5 years of progressive leadership experience in the implementation and management of Utilization Management, Case Management or Quality Management including business development and strategic planning. 6 years preferred

  • 3 years of supervisory/management experience in an ambulatory or acute care setting. 5 years preferred

  • Strong project management and operations experience

  • 3 years of compliance and oversight experience

  • 3 years of experience in a healthcare organization working with a health plan and/or government regulations

  • Basic computer skills in a Windows operating environment including Microsoft Word, Excel, and an e-mail system

  • Must be a dynamic leader, able to navigate a complex environment, with excellent verbal and written communication skills

  • Ability to drive innovation and take educated risks

  • Ability to effectively interact and establish immediate credibility with all levels of management, physicians, staff, patients, and community leaders

  • Knowledge of legal and medical requirements as applied to quality and risk management. Must understand credentialing requirements and the utilization review process

  • Knowledge of NCQA, JCAHO and other regulatory agency requirements pertaining to delivery of health care in the managed care setting

  • Effective influencing, negotiation, relationship-building and communication skills are essential.

  • Ability to work effectively under pressure due to changing priorities

  • Ability to work with Information Service department to maintain performance of computer hardware and software within the department

  • Effective employee management skills

  • Ability to lead through influence and persuasion

  • Ability to facilitate the integration of the finance, operations, and strategic functions of the organization

  • Possess strong leadership, critical-thinking and motivational skills/abilities

  • Knowledge of ambulatory healthcare delivery and management

  • Ability to build consensus across organizational lines

  • Ability to adapt quickly to changing conditions while managing multiple priorities

  • Ability to independently and self-direct activities

  • Excellent analytical, problem-solving, and organizational skills

  • Ability to work effectively and establish and promote positive relationships

  • Ability and willingness to travel within St. Joseph Health locations.

Preferred experience/education for this position include:

  • Master's Degree of Nursing, or related field.

  • Upon hire: Certification in CCM, ACM, CPHQ, or CPUR

  • Proficiency in all MS Office applications

  • Bilingual English/Spanish communication.

About Providence

At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.

Requsition ID: 131657
Company: Providence Jobs
Job Category: Health Information Management
Job Function: Revenue Cycle
Job Schedule: Full time
Job Shift: Day
Career Track: Leadership
Address: CA Anaheim 200 W Center St Promenade

Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.