• Manager for Utilization Review and Outpatient Clinical Operations

    Job Locations US-NV-Las Vegas
    Posted Date 2 days ago(1/14/2019 1:32 PM)
    # of Openings
    Medical Management
    Culinary Health Fund
  • Overview

    CHF logo with A division of UHH



    Our mission-driven organization is focused on the “Triple Aim” - Better Health, Better Healthcare and Lower Costs to individuals and their families who participate in our health plans.


    The Culinary Health Fund serves over 100,000+ workers and 220,000 covered lives in the hospitality and gaming industry. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity!



    Key Attributes:


    • Integrity – Must be trustworthy and principled when faced with complex situations

    • Ability to build positive work relationships – Mutual trust and respect will be essential to the collaborative relationships required

    • Communication – Ability to generate concise, compelling, objective and data-driven reports

    • Teamwork – Working well with others is required in the Fund’s collaborative environment

    • Diversity – Must be capable of working in a culturally diverse environment

    • Continuous Learning – Must be open to learning and skill development.  As the Fund’s needs evolve, must be proactive about developing new areas of expertise

    • Lives our values – Must be a role model for the Fund’s BETTER Culture and Mission (Better, Engage, Teamwork, Trust, Empower, Respect)



    • Oversee and manage the Utilization Review and Population Health staffs and programs
    • Manages and evaluates team members in the performance of various utilization management activities through various reporting and auditing activities.
    • Maintain and monitor timely reviews in accordance to URAC and NHS Policy and Procedure standards
    • Monitor metrics and develop reports
    • Participate in all functions that will maintain the organizations URAC accreditation
    • Review for trends and escalate to management patient issues, barriers etc.
    • Contributes to UM program goals and objectives in containing health care costs and maintaining a high quality medical delivery system through the program procedures for conducting UM activities;
    • Performs telephonic review for inpatient and outpatient services using InterQual, Milliman criteria or internal criteria
    • Keeps current with regulation changes and informs the Utilization Management staff of all up-dates and changes
    • Coordinates the integration of utilization nurses’ activities
    • Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and performance indicators
    • Conducts self in a professional manner at all times
    • Assists team members in improving skills, creativity and problem solving.
    • Collects only pertinent clinical information and documents all UM review information using the appropriate software system
    • Promotes alternative care programs and researches available options including costs and appropriateness of patient placement in collaboration with plan benefits
    • Communicates directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services
    • Communicates directly with the designated medical director regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues
    • Recommends, coordinates and educates providers regarding alternative care options
    • Maintains an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital and health plan client discharge planners and social workers in the early identification of potential home care candidates or less restrictive level of care placement
    • Participates in UM program CQI activities
    • Follows relevant time frame standards for conducting and communicating UM review determination
    • Maintains and submits reports and logs on review activities as outlined by the UM program operational procedures
    • Identifies and communicates to the Director of Medical Management all hospital, ancillary provider, physician provider and physician office concerns and issues
    • Identifies and communicates to Director of Medical Management all potential quality of care concerns and patient safety
    • Serves as liaison for provider staff and the client
    • Maintains courteous, professional attitude when working with the Client’s staff, hospital and physician providers, and all ancillary providers
    • Identifies and communicate all catastrophic and high risk cases for case management referral
    • Active participation in Quality and UM committee meetings
    • Participate in management call rotation
    • Performs other duties as assigned within the scope of responsibilities and requirements of the job
    • Performs Essential Job Functions and Duties with or without reasonable accommodation



    Years of Experience and Knowledge

    • Minimum 2 years of experience in utilization review, quality assurance, discharge planning or other cost management programs preferred
    • Minimum 2 years of directly related experience using InterQual or Milliman criteria or healthcare criteria preferred
    • 3 years of experience in hospital based nursing required. Medical surgical care experience preferred for positions in medical management areas
    • Minimum 3 years of management experience in a healthcare environment preferred

     Education, Licenses, and Certifications

    • Associates or Bachelor’s degree in Nursing
    • Unrestricted active RN License in the State of Nevada.
    • Willingness and ability to obtain a license in other States as may be required by the Fund

    Skills and Abilitie

    • Microsoft Office skills (PowerPoint, Word, Outlook)
    • Microsoft Excel skills
    • Preferred fluency (speak and write) in Spanish
    • Excellent written and verbal communication skills
    • Excellent interpersonal skills – ability to express compassion and balance the emotions with business needs
    • Strong communication, documentation, clinical and critical thinking skills essential
    • Working knowledge of utilization management required
    • Strong problem solving and decisions making skills essential
    • Communicate clinical information to non-clinical individuals
    • Manage competing deadlines and multiple projects in a fast-paced environment


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