Chief and KFH/TPMG
Case Management - Utilization Management
COMPANY: For more than 60 years, this company has been dedicated to
improving the health of their members and the communities
we serve, by creating safe, healthy environments and
providing quality health care and coverage for all.
LOCATION: San Jose, California
DESCRIPTION: Develops, coordinates and manages the administrative and
operational activities that are directly associated with the
utilization management of medical services provided to
Kaiser members. Works independently; establishes priorities
: Chairs and Co-chairs local committees focused on creating,
implementing and monitoring work plans to achieve UM
targets and performance improvement. Provides expertise
into target setting processes. Shares accountability with
other medical center leadership for the daily monitoring of
utilization indicators and performance, identification and
escalation of problems, and initiation and evaluation of
action plans for achieving medical center targets and
improve the quality of care and services. Participates and
provides UM expertise on local and regional committees,
including UM Peer, UM Chiefs/Directors, Quality, TPMG,
other departments and contracted/planned providers.
Manages projects related to chart reviews.
: Conducts utilization data analysis (avoidable days,
readmissions, UMAB, PRS reports, one-day stays, DRGs,
LOS, PDRs, etc.) for trending and development of
performance improvement initiatives. Partners with the UM
Chief and KFH/TPMG local medical center leadership, to
engage the following areas in the development and
implementation of a comprehensive utilization management
work plan to meet or exceed medical center targets:
Physicians, managers across the continuum, and TPMG/KFH
service leaders and managers. May include oversight of the
coordination of KP members' care with leaders responsible
for UM activities associated with alliance/contract hospitals
: Links with the Quality Department to ensure quality
improvement, risk, and safety management activities are
aligned with local UM initiatives.
: Identifies and incorporates (as appropriate) evidence-
based best/successful practices (e.g. care paths, innovative
discharge planning / case management models, etc.) into
efforts to improve quality of care/service and reduce costs.
: Collaborates with interdisciplinary teams across the
continuum of care including, but not limited to (HBS, TPMG
Sub-specialty departments, Nursing, MSW, PT/OT, HH,
Hospice, SNF, CCM, Behavioral Health, Rehabilitation, etc.).
to ensure patient care is effectively provided, clinically
appropriate, service oriented, safe and cost effective.
Partners with TPMG to provide UM related education and
training as needed.
: Ensures compliance with regulatory/accreditation (NCQA,
MDQR, CMS, Medi-Cal, DMHC, DOL, JCAHO,etc.)
requirements related to UM by partnering with other
departments and facilitating workgroups in maintaining
: HR related activities (average 18 employees): Manages
and resolves human resource, employee, department safety,
and risk management issues. Responsible for all aspects of
staff management including, hiring, development/training,
performance reviews and terminations.
: Manages department budget and finances. Develops
implements, and monitors departmental policies and
: Three (3) or more years of experience in management
/leadership in a hospital or outpatient setting.
: Minimum three (3) years of previous experience in
utilization management activities required.
: Master's degree preferred.
: Knowledge of the Nurse Practice Act, JCAHO, NCQA, and
other local, state, and federal regulations.
: Demonstrated skills in leading and facilitating the efforts of
: Demonstrated strong communication, problem-solving and
: Must be able to work in a Labor/Management Partnership
EDUCATION: Graduate of accredited school of nursing.
BSN or BA in health care related field OR four (4) years of
experience in a directly related field required.
License, Certification, Registration
Current California RN licensure