SCOPE OF ROLE

The Manager of Discharge Planning, Utilization Management leads a team of Discharge Planning nurses that are responsible for supporting Bright’s Discharge Planning function. The manager is responsible for clinical staff in the department activity surrounding discharge planning and follow-up. The department's activity may involve intake referral processing, provider coordination and authorization, and/or completion of the eligibility, benefits, authorization process, and member coordination of care. The Manager ensures that services utilized comply with authorization and utilization management guidelines. The Manager will also monitor the performance of the team and individual members and takes appropriate action to ensure department goals are met and that staff are utilizing appropriate guidelines to make medical necessity decisions. This individual will serve as a role model for team members, assuring both members and providers have a positive experience with the services they receive. This position is also responsible for ensuring the Discharge Planning team is working to achieve expected clinical outcomes. The Manager Discharge Planning, Utilization Management ensures all related initiatives meet all applicable state and/or federal regulatory requirements in addition to corresponding URAC standards.

ROLE RESPONSIBILITIES

• Provide leadership and direction to a team of Discharge Planning Nurses, inclusive of performance oversight, monitoring the quality of work the team does, and ensuring the team is working to achieve expected clinical outcomes.
• Support staffing and scheduling plans to meet departmental objectives as provided by leadership, including meeting specified service levels.
• Monitor operational key performance indicators to track service delivery against targets.
• Recruit, hire, and train new team members.
• Enforce UM policies and procedures to ensure compliance with state and federal agencies as well as accreditation standards.
• Support the development and maintenance of standard operating procedures related to corresponding program functions.
• Participate in the development of operating models to execute utilization management solutions.

SUPERVISORY RESPONSIBILITIES

• This position has Supervisory responsibilities for members of the Utilization Management team.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• A minimum of an associate degree in Nursing is required.
• Three (3) or more years of Supervisor experience within a consumer support function
• Two (2) or more years of healthcare-related experience
• Awareness and experience with HIPAA requirements for healthcare communication
• Prior experience with URAC accreditation is desired, but not required
• Formal training in Six Sigma management techniques is desired, but not required

LICENSURES AND CERTIFICATIONS

• An active, Registered Nurse (RN) or Licensed Practical Nurse (LPN) license to practice as a health professional in a state or territory of the United States is required for this role.

WORK ENVIRONMENT

• The majority of work responsibilities are performed in a call center environment, carrying out responsibilities sitting/standing at a desk/table and working on the computer.
• Travel is not required.

For individuals assigned to a location(s) in California, Bright Health is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant’s education, experience, skills, abilities, and internal equity. A reasonable estimate of the range is $86,078.21 - $129,117.31 Annually.

Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; up to 21 days of PTO, 10 paid holidays, plus 2 floating holidays per year; and a lifestyle spending account.