Job Description

Location: Novato

Employment Status: Full Time

General Statement of Duties

In collaboration with the Chief Medical Officer and Medical Director, the UM Manager develops, manages and directs the organization’s Utilization Management department to assure compliance with all health plan and government requirements and is responsible to ensure the organization passes all required audits, including HEDIS and NCQA.

Principle Accountabilities

Provide overall direction, design, implementation, and monitoring of utilization programs to meet the organization’s utilization goals while maintaining customer satisfaction

Provide overall supervision and guidance to clinical RN and administrative UM staff.

Develop and implement the annual Utilization Management Program and work plan.

Oversee the daily utilization management activities, including referrals and authorizations, concurrent inpatient reviews, and compliance with all required regulations and contractual obligations.

Develop guidelines for appropriate patient referrals to Complex Care Management.

Work in collaboration with partner hospitals to develop policies to ensure appropriate repatriation of members from out of network facilities

Develop reporting to review utilization patterns and trends and out of network utilization to assist in identifying appropriate interventions

Act as principal staff for the UM/QA Committee – set monthly agenda, provide data and other information

Monitor all catastrophic cases and report for reinsurance and case management.

Develops and maintains relationships with health plans to provide accurate interpretation of benefits and provide oversight for outside medical services based on Health Plan benefit guidelines and medical necessity

Assure compliance of all policies and procedures to ensure the organization passes health plan audits

Develop, implement and oversee reporting and other data analytics to identify high/low cost physicians, facilities, home health agencies and other providers

 

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Job Requirements

Education, Experience and Qualifications

RN required, BSN a plus, Bachelor’s degree in healthcare related discipline highly desired.

Excellent leadership, interpersonal, collaboration and communication skills.

Proficiency in the area of developing, managing, and reporting clinical and business analytics and metrics. Knowledge and experience using Lean Six Sigma concepts and tools highly desirable.

3 + years of current related leadership in Managed Care required.

Experience in quality, discharge planning, utilization management, home care, and complex care management preferred.

Demonstrated knowledge of DMHC, Medicare, Medi-Cal, and other local, state, and federal regulations.

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Benefits

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Job Description

Location: Novato

Employment Status: Full-time exempt

The Clinical Data Analyst reports to the Director of IT

Position Summary:

• Assist and support various company initiatives in many departments across the organization.
• Help the company, it’s functional areas, and it managers meet their operational and strategic goals through data analysis and reporting.
• Drive insightful analyses of clinical, financial and operational data to determine opportunities for increased levels of patient care, cost reductions, increased revenue, operational efficiencies, and various other objectives.
• Gather, research and analyze clinical and claims data to help measure and improve clinical performance against industry standards, and identify areas for improvement
• Build models and processes to identify and track high-risk and high cost patients, help to recommend interventions, and measure effectiveness of interventions implemented by managers.
• Create in-depth reporting of clinical, financial, and operational metrics for internal and external stakeholders, and present and communicate findings at various meetings.
• Develop new processes, reports, and analysis tools to deliver impactful and actionable insights that drive decision making 

Core Requirements

• Experience working with electronic health information and an understanding of the general architecture of Electronic Health Records and related operating systems.
• Experience with relational databases with complex architecture and table structure.
• A high level of proficiency with data management and analysis tools such as: SQL Server Management Studio, Microsoft Access, Power BI, and Excel.
• Ability to develop and support in-depth reports that show nuanced and complicated clinical data, including the ability to teach end users how to interpret content
• Excellent written and verbal communication skills, including designing reports and presenting to internal and external groups.

Traits and Capabilities

• Ability prioritize workload to meet deadlines for short and long-term goals with competing timeliness.
• Critical thinking and independent problem resolution skills.
• Demonstrated ability to understand and effectively facilitate communication among team members and physicians.
• Ability to quickly learn and master new software systems.
• General ability with financial analysis preferred
• Ability to work outside of normal business hours as necessary

Software and Tools

• Proficiency with or the ability to learn how to work in a Microsoft Office environment: Outlook, PowerPoint, Visio, Excel, Word, Power BI, OneNote, etc.
• Proficiency with or the ability to learn how to use project management and collaboration software: Asana, SharePoint, Microsoft Teams

 

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Job Requirements

Requirements:

• 2+ years of current clinical analytics experience
• A background in at least one of the following areas: Risk Adjustment, HMOs, ACOs Health Plans, Utilization Management, Case Management, Pay for Performance, 5 Star, etc.
• Bachelor’s degree in one of the following areas: Statistics, Computer Science, Data Science, Informatics, Population Health, Healthcare Administration, Finance, Economics, etc.
• Masters’ Degree preferred

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Benefits

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Job Description

Location: Novato

Employment Status: Full Time

General Summary

This position coordinates utilization review and case management activities for commercial and Medicare enrollees.  The Utilization Management nurse is knowledgeable about the Nurse Practice Act, NCQA, Millman Care Guides, and the Center for Medicare and Medicaid, HMO timeliness rules and pertinent state and federal regulations.

• Review routine referral/service requests on assigned patients in accordance with NCQA timeliness standards and health plan benefit structure.
• Prepares and presents cases for medical director review in a concise, objective and organized manner.
• Assists with identifying patterns and trends and develops and implements corrective actions when necessary.
• Educates and supports members in the accessing care using their HMO and Medicare Advantage benefits as needed.
• Review routine referral/service requests on assigned patients in accordance with NCQA timeliness standards and health plan benefit structure.
• Identifies and refers patients to disease management, wellness programs and community resources whenever relevant.
• Assesses members’ physical, psychological, social, environmental, financial and functional status as necessary and informs the patient’s treating physician of clinically relevant findings e.g. positive score of depression screening, non-compliance with the plan of care and barriers t treatment.
• Collaborates with the concurrent review.

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Job Requirements

Qualifications

Education: 

• Current California RN License with no restrictions
• BSN Preferred

Experience:   

• Minimum five years of clinical experience.

• Experience strongly preferred in one or more of the following: HMO, Health plan, Medicare, Utilization Management, Case Management

Knowledge, Skills, and Competencies

• Ability to understand and facilitate communication among team members, patients, families, physicians and medical office staff.
• Ability to communicate effectively with contracted health plans and meet required turn around times
• Good clinical judgment, critical thinking skills and independent problem resolution
• Ability to organize and prioritize workload
• Good working knowledge of Microsoft Office, Outlook, EHR, prior Health Care Management/authorization software.

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Benefits

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Job Description

Location: Novato

Employment Status: Fulltime

Business Intelligence (BI) Analyst, Lead

The Business Intelligence (BI) Analyst, Lead develops and supports the transformation of data into information to provide actionable insights to enhance and expand the quality, efficiency, and cost effectiveness of products and services provided by Meritage Medical Network to its members, physicians, health plans, and staff.

The BI Analyst Lead utilizes established data sources within SQL, Access databases, Excel tables and Power BI  to collect, integrate, extract, analyze and present information in reports, dashboards, and key data visualizations. The BI Analyst Lead, under direction of the IT Director, provides analytics staff work distribution, peer review, and coaching.

The preferred candidate demonstrates advanced SQL, Access, Excel and Power BI skills to create data views, reports, extracts, and visualizations within a healthcare managed care environment.

Essential Job Functions

Ability to transform data into actionable and tailored information visualizations designed for specific issues, operational and/or executive decisions and insights.

Regularly applies conceptual knowledge, analytical methods, and problem solving skills to perform assignments and improve efficiencies within existing systems, processes, functions, and applications.

Provides IT solutions and services which ultimately contribute to physician efficiency, productivity, quality, and organizational clinical, operational, and financial performance.

Advanced analytical and problem solving skills.

Determines operational feasibility by evaluating analysis, problem definition, requirements collection, solution development, and proposed solutions.

Documents and demonstrates solutions by developing documentation, flowcharts, layouts, diagrams, charts, code comments, clear code and appropriate metrics.

Project management training & skills to organize, document, monitor, manage, and communicate project status, issues, risks and associated mitigations and/or resolutions.

Prepares and installs solutions by determining and designing system specifications, standards, and programming.

Improves operations by conducting complex systems analysis, tracking metrics, recommending changes in processes, policies and procedures.

Develops advanced solutions by studying information needs; conferring with users; studying systems/data flow; data usage, and work processes; investigates problem areas; follows industry standard/best practice for software development life cycle.

Ability to be flexible in an environment of changing priorities and work both independently and in a team.

Self-motivated with the ability to prioritize, meet deadlines, and manage changing priorities.

Key Responsibilities

Works closely with end users to understand their business needs in relation to software functionality.

Analyzes software problems and business data requiring complex methods to ensure accurate findings and applicable recommendations.

Designs, delivers, and improves software applications training programs and related courseware.

Understands the end users’ business needs, works closely with them to provide solutions, and aligns end user business needs with high levels of application functionality.

Provides technical support to less experienced information systems analysts.

May serve as a liaison between vendors, IT, and internal customer to ensure service delivery agreements are met and that return on investment is realized.

Updates job knowledge by studying state-of-the-art analysis, visualization, and development tools, programming techniques ;participates in educational opportunities; reads professional and technical publications; maintains personal networks; participates in professional organizations

Complies with MMN’s Policies/Procedures protecting patient information and the confidentiality of the information in accordance with the Federal and State regulations.

 

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Job Requirements

• Bachelor’s degree in related healthcare, business, computer science, information sciences, software development/analysis or related field preferred; experience or alternative degree or alternative knowledge acquisition may be considered in lieu of education.
• Minimum of 6 years of experience within a data analysis environment, with 4 of those years preferably within a healthcare related and/or managed healthcare setting preferred; alternative experience acquisition or a combination may be considered in lieu of required experience.
• Demonstrated knowledge of concepts, practices, processes and procedures used specifically within a managed healthcare environment.
• Previous experience in the analysis, development, support, maintenance and training of a OTF and developed systems required.
• Demonstrated advanced skills in developing solutions in environments that are most applicable to the project requirements, including but not limited or exclusive to: Database (SQL, Access); Spreadsheets (MS Excel); Data Visualization (Microsoft Power BI); FTP scripting; Crystal Reports;  a plus to have:  Web (HTML, CSS, JavaScript, AngularJS, etc.); Desktop (.Net, C#, VB, etc.); etc.
• Strong skills using MS Office 365 – Outlook, Access, Excel, Word, PowerPoint, Skype, Teams, and Visio.
• Familiarity with specialty applications for project and resource collaboration (e.g., SharePoint, Asana, MS Teams)

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