Responsibilities Come and join the RMC Family! We have been in the community since 1935. Our mission is to provide comprehensive multi-specialty medical services in the greater Riverside region. Your passion, inspiration, and talents are invaluable to us and our mission to serve others. Our facility can provide a place for you to thrive and continue your professional development. Quality Healthcare is our passion, improving lives is our reward. We are working to change lives and transform the delivery of healthcare. Riverside Medical Clinic is the best place to work, practice medicine, and receive care. SUMMARY: Responsible for the processes of evaluating the necessity, appropriateness, and efficiency of outpatient/ambulatory services per health plan and regulatory standards. Assists the Manager of Medical Management and/or the Regional Director of Quality Risk serves as the liaison with the physician advisor for the referral of unusual questionable cases, on referred cases for reconsideration, and to obtain authorization for the issuance of denial letters. 2. Confers with physicians, administrative personnel, and other disciplines to coordinate the work of the unit, obtain information, answer questions concerning the necessity for utilization review, and develop review procedures. Resolve escalated issues from external and internal customers. 3. Establishes work procedures and evaluates processes for improvement. Monitor staff production and turnaround time on a daily, weekly, and monthly basis to ensure accuracy, production, and attaining department goals. 4. Prepare and authorize work schedules for UM Coordinators, maintain attendance records, and update payroll systems. 5. Develop and implement monthly utilization statistics, as necessary, for use in the Utilization Management Department and Utilization Management Committee. 6. Determines the need for and conducts in-service training to improve the quality of pre-service/pre-certification reviews, and to disseminate information concerning new or revised procedures. 7. Reviews utilization review records for completeness, use of appropriate codes, the correctness of primary reason and indication for the service/referral requested, and inclusion of all relevant supporting medical information. 8. Review and update authorizations on the system to ensure timely turnaround and compliance with health plan requirements. 9. Serves as a technical resource person to direct reports concerning Federal and State regulations on Medicare and Medi-Cal reimbursement, aspects of medical treatment for unusual illnesses and diseases, and interpretation of review procedures and standards. 10. Responsible for interviewing, hiring, training, coaching, counseling, and termination of employees. 11. Conduct introductory assessment and annual performance evaluation as required. 12. Ensure all documentation of employee issues, training records, and any related company policies and procedures comply with governmental and company protocol. 13. Conduct monthly staff meetings. 14. Assists the Regional Director of Quality Risk and listed in Forbes ranking of America's Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. Avoid and Report Recruitment Scams At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.
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