Job Title: Resource Utilization Management Director Position Summary:Manages various Continuing Care departments as assigned, which may include 24 hour and/or multiple location departments. Plans, organizes, directs, evaluates, and coordinates services across the continuum of care within a Service Area, a single medical center or a Regional service. Oversees utilization in continuing care programs. Partners with the Hospital discharge planning and social needs of member population.Responsible for establishing, implementing and maintaining the components of the Resource Management process that is focused on the achievement of satisfactory patient outcomes within specific timeframes through the appropriate utilization of available internal and external resources. Accountable for providing oversight of the utilization management functions within the organization as directed by its policies and procedures.Coordinates with the Hospital and appropriate Hospital staff to provide for the seamless transition of patients across the continuum of care. Works with the Hospital and the Medical Group staff developing strategic plans, providing quality care, cost effective services which are aligned with federal, state, and local regulations. Represents Health Plan for Hospital operations.Education/License/Certification: BSN or BA in health care related field required. Master´s degree preferred. Graduate of accredited school of nursing. Current California RN license required. BLS required.Qualifications: Substantial experience in-patient care (usually 8 years). Progressive management experience required (usually 5 years). Demonstrated knowledge of Knox, Keene Act, Federal HMO Act, Nurse Practice Act, JCAHO, and all other local, state, and federal regulations. Demonstrated strong interpersonal communication skills.Duties: Organizes, plans, directs and coordinates the Resource Management process assuring that the organizational goals and objectives are met. Directs development and implementation of quality and utilization standards across the Hospital continuum of care to ensure coordinated plans of treatment, customer focused delivery of services, and cost effective utilization of necessary services. Ensures compliance with administrative, legal and regulatory requirements of the Health Plan contract and governmental and accrediting agencies. Oversees the development of department standards as identified by regulatory agencies, including The Joint Commission, NCQA, CMS, DHS and DMHC. Maintains a state of continuous regulatory readiness Communicates regulations to the healthcare team and implements operational processes as a result. Maintains oversight of the concurrent and retrospective inpatient reviews and appeal process.Collaborates with other Service Directors in identifying and implementing innovative models and best practices, emphasizing service improvements and cost reductions. Develops services that achieve a high level of customer satisfaction with emphasis on customer service and highest standards of quality and innovation. Utilizes research data to implement clinical changes and the delivery of patient care and member services. Evaluates processes and makes recommendations to improve resource management systems and patient care outcomes across the continuum. Presents Executive Team with ongoing, reliable information about the treatment and patient flow throughout all levels of care. Leads the way in providing data that supports the processes of case management and demonstrates quality patient outcomes. Demonstrates competency in the assessment, range of treatment, knowledge of growth and development and communication appropriate to the age of the patient. Plans, organizes and directs all activities within areas of responsibility. Responsible for the efficient utilization of resources within and the effective customer service given by the department. Provides clinical and administrative direction to the staff. Responsible for maintaining a process for the ongoing education and competency and development of staff as a group and individually. Manages and resolves human resource, labor relations, employee, and department safety and risk management issues.Participates in region wide peer group and leadership activities to drive consistency of operations and performance improvement. Develops and manages systems and relationships with outside vendors; contract and quality oversight with external vendors.Develops budget and resource allocations for areas of responsibilities. Manages the financial performance and identifies and implements appropriate strategies to reduce costs and improve quality of care and services. Focuses on prevention/intervention and identification if issues/problems prior to their impact on operations and patient care; recommends and develops new programs for specialized patient populations to improve quality and effect improved utilization of services. Monitors utilization indicators; identifies and escalates programs; and initiates and evaluates action plans for achieving the areas utilization goals/targets.Consistently supports compliance and the Code of Conduct by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and the Hospitals policies and procedures. In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Hospitals Mission Statement, as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.