APLA Health's mission is to achieve health care equity and promote well-being for the
LGBT and other underserved communities and people living with and affected by HIV.
We are a nonprofit, federally qualified health center serving more than 14,000 people
annually. We provide 20 different services from 15 locations throughout Los Angeles
County, including: medical, dental, and behavioral health care; PrEP counseling and
management; health education and HIV prevention; and STD screening and treatment.
For people living with HIV, we offer housing support; benefits counseling; home health
care; and the Vance North Necessities of Life Program food pantries; among several
other critically needed services. Additionally, we are leaders in advocating for policy and
legislation that positively impacts the LGBT and HIV communities, provide capacity-
building assistance to health departments across the country, and conduct community-
based research on issues affecting the communities we serve. For more information,
please visit us at aplahealth.org.
We offer great benefits, competitive pay, and great working environment!
We offer:
• Medical Insurance
• Dental Insurance (no cost for
employee)
• Vision Insurance (no cost for
employee)
• Long Term Disability
• Group Term Life and AD&D
Insurance
• Employee Assistance Program
• Flexible Spending Accounts
• 12 Paid Holidays
• 3 Personal Days
• 10 Vacation Days
• 12 Sick Days
• Metro reimbursement or free
parking
• Employer Matched 403b
Retirement Plan
This is a great opportunity to make a difference!
This position will pay $80,683.20 - $104,116.36. Salary is commensurate with
experience.
POSITION SUMMARY:
This position is responsible for the management of the daily operations of Utilization
Management (UM) at APLA Health and Wellness (APLAHW). This position will ensure
that all processes, programs and operations of utilization management are fully
implemented for APLAHW.
The Utilization Manager will be proactive in establishing collaborative working
relationships with each member of the Care Delivery team to assure a sound Utilization
Management Program.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
• Develops and Implements a standardized Utilization Management Program to
ensure that all functions meet internal, Government, Health Plan/IPA and medical
group requirements.
• Ensures staff competency utilizing inter-rater reliability tools and evidence-based
criteria for utilization review.
• Develop, implement and maintain compliance, policies and procedures regarding
medical utilization management functions.
• Establishes excellent working relationships with all internal/external constituents
and staff, including the Chief Medical Officer, clinic directors and site medical
directors. Promotes collaborative relationships. Works cooperatively with other
managers in the Quality Department, including the quality manager and
risk/compliance manager.
• Participates in the collection, analysis and reporting of data relevant to utilization
management.
• Collaborates with the Quality Director to identify opportunities for process
improvements in Utilization management that are consistent with the
organization's vision and strategic long term goals.
• Develop, implement, and maintain utilization management programs to facilitate
the use of appropriate medical resources and decrease the business unit's
financial exposure.
• Compile and review multiple reports on work function activities for statistical and
financial tracking purposes to identify utilization trends and make
recommendations to management.
• Communicates with the staff both verbally and in writing to convey health plan,
contract or operations information to ensure all staff members have a consistent
and appropriate knowledge base to perform their duties.
• Promotes staff growth and development by identifying educational opportunities
to increase efficiency and maintain compliance with industry standards.
• Participates in staff meetings, assuring policy and procedures are adhered to
and, when necessary, modified to address changing strategic objectives.
• Supervise a staff of referral coordinators, currently consisting of one supervisor
and 5 other referral coordinators; Supervise at least 2 patient engagement and
retention specialists; Supervise at least 2 medical records coordinator.
• Optimize processes and workflows for the UM staff.
• Ensure the referrals staff are meeting key quality and risk management goals
and referrals are being properly tracked.
• Hire and train new UM staff as needed.
• Manage the medical group's referral filter tool, flagging questionable referrals for
further evaluation by the site medical director.
• Supervise staff who are monitoring patients in emergency departments and
hospitals in real time and ensuring that such patient receive appropriate follow up
by clinical staff. If necessary, this may require directly contacting patients to
coordinate care to minimize risk of hospital readmission.
• Ensure that high utilizing patients are appropriately engaged in case
management programs
• Report key UM metrics at monthly agency quality meetings
• Lead monthly UM committee meetings
• Other duties may be assigned to meet business needs
REQUIREMENTS:
Training and Experience:
• Five (5) years' utilization/care management experience in a clinical or managed
care setting preferred.
• Four (4) years management/supervisory experience (in a formal or informal role)
preferred.
• Requires either a Bachelor's degree in Nursing (RN with active California
certification) or other Healthcare related field like MPH, MHA, MBA/MS in
healthcare related filed
• Basic computer skills in a Windows operating environment including Microsoft
Word, Excel, and an e-mail system.
• Must be a dynamic leader, able to navigate a complex environment, with
excellent verbal and written communication skills, as well as strong operations
experience.
• Effective influencing, negotiation, relationship-building and communication skills
are essential.
• Effective employee management skills.
• Possess strong leadership, critical-thinking and motivational skills/abilities.
• Excellent problem-solving and organizational skills required.
Knowledge of:
• Knowledge of InterQual and/or Milliman software preferred.
• Knowledge of electronic health records systems (eclinicalworks preferred).
• Knowledge of ambulatory healthcare delivery and management.
• Knowledge of NCQA, DMHC, CMS and other regulatory agency requirements
pertaining to delivery of health care in the managed care setting.
Ability to:
• Ability and willingness to travel among APLAHW locations.
• Manage people through change.
• Demonstrate flexibility through change.
• Lead and form a collaborative team.
• Work effectively under pressure due to changing priorities.
• Independently and self-direct activities.
• Work effectively, establish, and promote positive relationships.
• Adapt quickly to changing conditions while managing multiple priorities.
WORKING CONDITIONS/PHYSICAL REQUIREMENTS:
This is primarily an office position that requires only occasional bending, reaching,
stooping, lifting and moving of office materials weighing 25 pounds or less. The position
requires daily use of a personal computer and requires entering, viewing, and revising
text and graphics on the computer terminal and on paper.
SPECIAL REQUIREMENTS:
Must possess a valid California driver's license; proof of auto liability insurance; and
have the use of a personal vehicle for work related purposes. COVID Vaccination and
Booster require or Medical/Religious Exemption.
Equal Opportunity Employer: minority/female/transgender/disability/veteran.