Utilization Management (Skilled Nursing Facility) Manager

Responsible for leading and managing the Utilization Management team, processes and procedures focused on appropriate Skilled Nursing Facility utilization. Role will ensure compliance with national, and state regulatory/accreditation requirements related to utilization management by partnering with other departments and facilitating workgroups in maintaining survey readiness to ensure that all annual requirements are met.

• Leads the SNF Utilization Management Department with a strong leadership presence and engagement to support the ongoing development and performance of everyone on the team.


• Manages the day-to-day utilization management function of a team or teams of clinicians ensuring the accurate and timely prior authorization of designated healthcare services, including concurrent and retrospective review of authorization requests.


• Runs daily, weekly, monthly, and ad hoc reports to monitor and analyze department performance, assess data against standards and goals, and identifies trends as appropriate.


• Manages and oversees the utilization review management training and education program for Utilization Review staff across the region.


• Works to develop, enhance and ensures workflows, policies, and procedures to support the efforts within the SNF utilization management team.


• Accountable for outcomes including, but not limited to skilled nursing admits per 1,000, and length of stay, escalation percentages, physician discordance rates, expected discharges dates, management of LOS 16+.


• Participates as a subject matter expert (SME) in internal cross-functional teams to ensure that utilization management programs meet regulatory requirements and elevates risk to leadership when programs are not in compliance. As well as ensures regulatory requirements are met and has continuous collaboration with quality and compliance teams.


• Manages regulatory audits including policy and file preparation.


• Collaborates and communicates with Patient Care Coordinators, Utilization Management Operations Center, MAPMG Physicians, and Health Plan leaders to develop, implement, and operate Utilization Management Activities.


• Partners with the Post-Acute Care Utilization Senior Director to develop and implement the staffing, education, mentoring, information technology, and data needed to enable post-acute care teams to successfully provide care to KP members.


• Regularly gathers data and utilization management metrics to support continuous improvement on the prioritized post-acute performance metrics.  Collaborates with the Senior Director of Post-Acute Care Utilization in supporting organizational goals.


• Other duties as assigned.