Providence Health & Services Regional Director, Utilization Management and Referral Operations in Mission Hills, California


Providence Health & Services - Southern California, Medical Foundation and Groups is calling a Regional Director, Utilization Management and Referral Operations in Mission Hills, CA.

In this position you will:

Responsible for EPIC functionality and interface performance to all referral and Authorization systems in PHS CA. Active in design and system stability, reporting and functional status with IT and Compliance Dept. inter-dependencies

• Active in PHS CA regional authorization system selection and interface design, build, implementation and functionality for all PHS CA Medical Groups, IPA network providers, contracted ancillary and medical provider network. Multiple EPIC and non-EPIC users will result in two parallel and integrated systems of referral and authorization submission and feedback, Close the loop to ensure optimal patient experience, enhance referral to preferred Providence network providers, and maintain required CA delegated model timeliness of decision making as applicable to HMO authorizations.

• Responsible for production teams specializing in EPIC referral processing as well as all HMO delegated model timeline adherence and reporting relevant to HMO authorization processing per CA HMO delegation schedule of monthly, quarterly and annual reports to Health Plan payers, CA PHS Medical Groups Board of Dir and Foundation Board of Directors.

• Able to maintain system integrity for patient service of all patient and provider notification letters required for all referrals including fee for service and HMO. Represents over 750,000 notifications annually in 2015 in CA.

• Active participant in PHS System EPIC Referral Advisory Committee with Admin Dir , Health Services for CA

• Assists in conducting projects and statistical studies in utilization trends, patterns, and outcomes as assigned. Works with Senior Contract Director of Provider & Ancillary Contracting and Network Management in trending Utilization and Cost variances. Manages contract transition plans with Senior Contract Director and Contract Directors in accordance with UM Medical Director and Administrative Director, Health Services. Presents findings and suggestions for improvement.

• Able to utilize evidence based statistical data and industry standards (CAPG, NCQA, and Advisory Board) to evaluate MG/IPA performance across PHS CA Regional UM referrals.

• Supports the quarterly/ periodic MG Provider or Board of Directors with standardized or customized data analysis and recommended options for improvement for presentations as directed by UM Committee MD Chairs of MG/IPAs meetings

• Plans, prepares and participates in Health Plan or other regulatory audits. Works closely with the MSO Regional Audit Manager in maintaining and/ or implementing new compliance requirements, focused on the ability to monitor and measure new processes electronically wherever possible and to enact regional standardization of compliance, with the understanding there may be MG/IPA variances in process.

• Maintains UM and Prior Auth /PPO Department Dashboards monthly. Reports to PHS CA Med Group and Foundations leadership, MSO Committee, All PHS CA Med Group UM Committees to include referral staff production and quality metrics, including all standardized metrics. Reviews such metrics with Admin Director monthly, gives feedback to Regional MSO UM staff and team meetings regarding goal measurements.

• Supports UM staff in addressing barriers or systems issues to expedite patient care.

• Provides direction to staff and develop optimal workflow regarding referral process and utilization review, care coordination, discharge planning, and delivery of services across the care continuum in conjunction with benefit/coverage interpretation with optimal efficiencies in application of health plan contracts.

Job Title: Regional Director, UM and Referral Operations

• Investigates and responds to client and provider complaints if referral process /staff impact quality of care and patient satisfaction with network providers and ancillary facilities. Works with Contract Director and MG/IPA various Contract Committees to define corrective action plans where needed and reports back to QM Medical Directors within MG/IPAs.

• Coordinates with the PHS CA MG/IPA Quality Management Departments to ensure that processes relative to referral management impacting quality improvement, risk, and safety management activities are aligned.

• Coordinates information with PHS CA MG/IPA Case Management Directors in leadership meetings, minutes of all meetings are maintained. Directs and coordinates clinical questions from all Referral staff with MG/IPA Case Management Directors and changes made to processes and policies are reviewed with Admin Dir., Health Services.

• Coordinates with MSO Claims Dept. to ensure all compliance and service, productivity objectives are efficient and consistently being met.

• Implements identified PHS CA MSO UM strategic initiatives to support the delivery of patient care at the direction of the Administrative Director, Health Services.

• Delivers upon the service expectations of both our patients and fellow staff members by listening to their needs; engaging in positive interactions; and following through on promises made in a thoughtful, efficient, timely and courteous manner so that their total outcome is better than expected.

• Respects the dignity, confidentiality and privacy of patients

• Communicates staffing skills, volume and overall system efficiency needs, including network needs, to the Admin Dir., Health Services.

• Manages the PHS CA Referral teams within the established MG/IPA budgets.

• Conducts Referral leadership team meetings on a monthly basis or more frequently if needed and maintains minutes of all meetings.

• Hires and retains qualified staff; ensures that new employees are oriented to their department, the system, and network and well trained for their jobs.

• Evaluates the overall MSO referral employees’ satisfaction and relationship with the immediate supervisor on a semi annual basis and provides constructive feedback to direct reports within the MG/IPA and to the Admin Dir., Health Services. Develops coaching, corrective action plans and utilizes progressive disciplinary processes according to policy.

• Oversees the organization of all Referral department workload standards and establishes work standards to promote efficiency and productivity. Oversees the maintenance of appropriate staffing levels and Regional UM Budget for referral systems staffing.

• Monitors the accuracy of all MSO generated UM authorizations and the impact on MSO or health plan claims processing and the clarity of the authorization copayment information for rendering providers and patients receiving authorized services.

• Writes and revises Regional UM Operations policies and procedure notices as needed.

• Provides assessment of individual performance of direct reports with fair and objective formal appraisal annually in a timely manner. Applies disciplinary action where appropriate and develops corrective action plan with employees, reevaluating performance as needed to measure progress.

• Motivates and manages staff to ensure that performance standards are met or exceeded. Assists staff with evaluation and responses to patient complaints. Assists staff in the development and reporting of relevant quality management indicators.

• Ensures that adequate clinical and non-clinical in-service education is available to direct reports and staff members. Documents the staff education and attendees annually for health plan compliance audits.


Qualifications for this position include:


· Masters or equivalent degree in healthcare related field required.

· Understanding of hospital and ambulatory care delivery systems required.

· Minimum 7 years experience in utilization management, discharge planning, ambulatory case management, quality management or clinical area in a managed care setting, preferably a health plan or medical group with 2 years in a management role.

· Demonstrated knowledge of operations. A minimum of two years’ experience with EPIC or similar EHR Referral systems operations and reporting .

· Knowledge of California Health and Safety Act, NCQA, DMHC, CMS and DHS regulations. Demonstrated ability to work and design work flows in a complex environment across PHS CA, medical groups/IPAs, Hospitals and care settings standardizing processes and goals.

· Experience assessing referral reporting needs for HMO compliance and Fee for service referral management.

· Able to evaluate software functionality and work with multidisciplinary teams to design systems work flow for UM Department functions in a managed care setting and fee for service patient care referral needs.

· Demonstrated strong oral and written communication, problem-solving and analytical skills as related to Utilization and Referral management data and analysis. Strong computer skills with MS Outlook, Word, Excel, use of Electronic Health Record and Referral software needs.

About the organization you will serve:

Providence Health and Services Management Services Organization (MSO) exclusively services the patient care and management needs of our risk bearing Medical Groups though our Foundations in California; Facey Medical Group & Foundation and Providence Medical Associates & Providence Medical Institute. We are located on a campus of ambulatory medical services in Mission Hills, CA and routinely provide on-site services throughout LA County. We service more than 125.000 managed care HMO lives, across 9 health plans for Commercial, MAPD and Managed care MediCal products. We have a centralized service team for our PPO prior auth services. We are actively involved in ACOs , Covered CA Exchange product management and a variety of innovations in care delivery and medical management in a close working relationship with leaders of our Providence affiliated Medical Groups. The PHS CA Medical Groups represent more than 400 staff model and IPA physicians working with over 1000 Medical Group network providers in the communities we serve . Our UM, CCM, Special Needs, QM, Credentialing, Eligibility, Claims, Revenue Recovery, Contracting , Network Management ,Insured Services, Provider Relations, Decision Support and Customer Services Departments are committed to timely and efficient service to our patients, providers and plan/community partners. We value compliance, integrity and high reliability in all endeavors . We participate and serve on many professional and community boards to fulfill our Providence mission to serve those in need , in particular, the poor and vulnerable of California.

We offer a full comprehensive range of benefits - see our website for details

Our Mission

As people of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.

About Us

Providence Health & Services is the third largest not-for-profit health system in the United States. Providence employs more than 76,000 caregivers (employees) across a five-state area; AK, WA, MT, OR, and CA. Our facilities include 34 hospitals, 475 physician clinics, senior services, supportive housing and other health and educational services. 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.

Schedule: Full-time

Shift: Day

Job Category: Director / Executive

Location: California-Mission Hills

Req ID: 132955