Summary: This role is key to the success of the Managed Care (MC) Department and is accountable for overseeing and carrying out GMG’s UM Program. Serves as the operational liaison with contracted Managed Care health plans/entities. Ensures that Delegation Agreement responsibilities are fulfilled. Works closely with clinical teams, providers and other GMG departments to achieve organizational goals, and an efficient and effective UM/QI process. Provides training and ongoing support to GMG Providers and the staff.
Plans, directs and coordinates GMG UM Program activities and UM operations.
Oversees daily review process: prospective, concurrent, retrospective reviews to ensure proper protocol is being followed.
Oversees Patient Care Committee meetings to ensure reviews, decisions, appeal determinations are properly considered, documented and reported.
Participates on the Quality Improvement committee to ensure that UM/QI is carried out per GMG UM Program.
Develops and Maintains UM database, monitoring documentation accuracy, data integrity and UM performance.
Responsible to ensure Delegation Agreements are carried out appropriately and that GMG and MC health plan/entities are meeting obligations.
Identifies opportunities for operational improvement, and works collaboratively with the UM team, Provider PODS, and other GMG departments. Communicates effectively with clinic staff, internal providers, patients, and external providers regarding UM issues, results.
Develops training and ongoing support for GMG Providers and their staff so they are able to successfully follow and contribute to UM process.
Sets annual departmental goals and objectives and takes responsibility for their achievement. Effectively engages Managed Care/UM staff in accomplishment of goals.
Active participation and support of GMG and Managed Care strategic goals/initiatives, committees and workgroups.
Develops, reviews, and maintains UM policies and procedures. Participates in the development of organizational policies and procedures.
Ensures staff members follow departmental and organizational policies and procedures, including thorough knowledge of the UM process and compliance with GMGs mission, vision, values and behavioral expectations.
Provides clear directions, consistent and timely feedback to Managed Care UM staff. Promotes teamwork in daily activities, exercises diplomacy and consistently uses effective communication skills, acting as a role model to employees.
Responsible for the hiring, training, on-going supervision, discipline and evaluation of UM team staff. Provides a comprehensive orientation and ongoing staff development. Provides timely comprehensive staff evaluations.
Supports GMG goals by actively participating in Orientation, Training Programs, Task forces, Project Teams and other special endeavors.
Ensures that Managed Care UM staff maintains strictest member and company confidentiality; ensures member health information is secured each day; HIPAA knowledge and focus.
Able to work efficiently under pressure.
Performs other duties as assigned.
Education and Experience: Minimum Associates Degree Required. Prefer BS, BA or Masters in Nursing or healthcare related field. Requires at least 5 years experience in Managed Care, and Utilization Management experience. Prefer supervisory/management experience of at least 3 years. Must be able to use basic office equipment. Must have knowledge of ICD-10 and CPT-4 coding, medical terminology. Must have strong verbal and written communication skills.
Computer Skills: Knowledge of Word Processing software, database software, spreadsheet and Internet software
Gonzaba Medical Group’s founder, William Gonzaba, M.D., started his family practice in 1960 on South Flores Street, not far from the neighborhood where he was born and raised. In the early 1980s, he brought in additional doctors to help him with a growing patient population. Soon, the doctors outgrew the South Flores clinic. Dr. Bill Gonzaba looked a few blocks down the street to the old Pan Ameri...can Restaurant building and decided to give the landmark building a new life in the healthcare industry. After nine months of planning and renovation, Gonzaba Medical Group reopened in 1986 as a state-of-the-art medical complex.
Today, Gonzaba Medical Group includes an outstanding team of physicians who share the same commitment to quality care and customer service as the group’s founder. Led by Dr. David Padilla, the group includes a team of more than 50 physicians, hospitalists, physician assistants and nurse practitioners serving in five locations throughout the city. With a support staff of hundreds of individuals, expanded and updated facilities as well as the latest diagnostic capabilities, Gonzaba Medical Group continues to change the way healthcare is delivered while staying true to its core principle: “the patient always comes first.”
To serve our patients Como Familia - Like Family
To provide an innovative system of medical care that delivers with integrity every day.
To be a physician-led, patient centered, high performing medical group that provides value-driven answers to the high cost of health care.
• Purpose – We are called to serve our patients como familia
• Action – We deliver highest quality care at the lowest cost with compassion and respect
• Superior Service – We work responsibly as a team to earn your trust
• Integrity – We do the right thing every day
• Obligation – We embrace transparency, accountability and measurable results
• New Ideas – We lead innovation in the practice of medicine