The Concurrent Review and Care Transitions Manager is responsible for carrying out concurrent review and care transitions daily operations. You will establish operational objectives for concurrent review and care transitions and delegate to staff as necessary and will interact cross-functionally and with varying leadership levels to collaborate on internal projects and external relationships.
The successful candidate should have outstanding organizational and interpersonal skills, be a leader who excels at motivating people, and takes pride in exemplary teamwork and enjoys working in a fast-paced, dynamic department that is in the middle of substantial growth and change.
WHAT YOU WILL DO
- Manage the Concurrent Review team, including remote nurses and on-site care transitions resources.
- Serve as liaison to acute care and post-acute care hospitals to ensure SFHP members are receiving appropriate care.
- Develop and manage the care transitions program.
- Ensure NCQA, DHCS, and DMHC regulatory compliance in concurrent review and care transitions.
- Review utilization management metrics and provide analysis and action plans for over and underutilization, readmission rates, and trending.
- Assure effective collaboration between UM functions and care management and care coordination pharmacy programs.
- Act as interim concurrent review and care transitions lead for escalating concerns when the Director, Clinical Operations is not available.
- Work with Director, Clinical Operations and Medical Director(s) to ensure appropriate clinical criteria are developed and practiced.
- Inpatient utilization management including review of clinical requests, and coordination with the Medical Director(s) to ensure members receive appropriate services within their medical group.
- Collaboration with hospital leadership staff to build quality, cost-effective care transition processes.
- Oversee quality initiatives and metrics for Concurrent Review Team.
- Ensure appropriate documentation of Concurrent Review and Care Transitions processes and procedures.
- Collaboration with Medical Director, Director, Clinical Operations and Prior Authorizations Senior Manager to develop and implement clinical criteria to ensure evidence-based care that reflects current regulations and SFHP policy.
WHAT YOU WILL BRING
- Valid unrestricted Registered Nurse or Nurse Practitioner license in the state of California.
- A current CA RN license to practice without restriction.
- Two to five years experience in an acute care setting preferred.
- Two to three years of people management experience.
- Managed care experience in case management, resource management or utilization review preferred.
- Demonstrated ability to lead staff and collaborate effectively with internal and external stakeholders.
- PC literacy and demonstrated experience with MS Office (Word, Excel, PowerPoint).
- Excellent oral and written communication skills.
- Ability to work with socially and ethnically diverse populations.
- Experience with Medi-Cal and or Department of Healthcare Service regulations and standards preferred.
- Proficiency with PC-based computer systems, ability to learn new information systems and software.
- Experience with managed care systems or electronic medical record preferred.
Established in 1997, San Francisco Health Plan (SFHP) is a an award winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco county. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 145,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. SFHP was designed by and for the residents it serves, and takes great pride in its ability to accommodate a diverse population that includes young adults, seniors, and people with disabilities.
San Francisco Health Plan is an Equal Opportunity Employer (EOE) M/F/D/V
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.