Manager, Utilization Management
Posted on: November 16, 2021
Other opening in Orange, California. This and other nursing
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Manager, Utilization Management
Department(s): Utilization Management (Delegate Monitoring)
Reports to: Director, Utilization Management
FLSA status: Exempt
Salary Grade: P - $117,000 - $165,000
This position manages the work activities of the Utilization
Management (UM) Delegate Monitoring team to ensure that service
standards are met, and operations are consistent with all
regulatory requirements, accreditation standards and CalOptima
policies and procedures. In addition, the incumbent is responsible
for the management of the day-to-day monitoring of delegates and
CalOptima's UM activities, including monitoring of UM processes of
Prior Authorization, (outpatient) concurrent and retrospective
review for delegates and the CalOptima Community Network (CCN). The
incumbent works closely with key internal and external stakeholders
relevant to prior authorization.
• Manages the day-to-day activities of Delegate Monitoring to
ensure compliance with regulatory requirements, accreditation
standards, and CalOptima policies.
• Interviews, onboards, trains, manages, motivates, supports, and
• Mentors and facilitates the ongoing development and education of
UM department staff.
• Develops, establishes, and maintains a work priority system to
ensure daily and heavy workloads are fulfilled.
• Collaborates with the Director to ensure appropriate monitoring
of delegate performance and identify compliance issues identified
are remediated in conjunction with the health network and the CCN
• Research regulations and informs delegates of CalOptima and the
CCN team of any changes to regulatory requirements.
• Participates in workgroups that addresses both clinical and
non-clinical internal activities that CalOptima must demonstrate
improvement to meet its contractual requirements with the Center
for Medicare and Medicaid (CMS), California Department of Health
Care Services (DHCS), California Managed Risk Medical Insurance
Board (MRMIB), Department of Managed Health Care (DMHC), and any
other applicable entity.
• Facilitates improvement teams as assigned by the director and/or
• Educates CalOptima staff and health networks on
• Partakes in Audit & Oversight Committee meetings.
• Presents monitoring findings at the Utilization Management
Committee (UMC) and other committees as requested.
• Ensures that all reviews for medical appropriateness use
established criteria to determine the medical necessity of the
• Demonstrates support of the CalOptima's goals and priorities,
with attention to managing department monitoring activities that
are cost-effective in terms of resources, material, and time.
• Assists in the annual review and revision of CalOptima policies
and procedures and UM department desktop procedures as required by
benefit plan changes guidance from CMS and DHCS.
• Assists the Director of Utilization Management in all areas of
the department, as requested, to ensure department and
organizational goals are met.
• Other projects and duties as assigned.
Possesses the Ability To:
• Manage change and help to motivate the team.
• Have strong team leadership, problem solving, organizational, and
time management skills with the ability to work in a fast-paced
• Maintain confidentiality of member's medical information.
• Maintain effective interpersonal relationships with all levels of
staff, other departments, programs, and agencies.
• Organize and administer a complex project plan for the
achievement of organizational and audit & oversight goals and
• Demonstrate and motivate others in effective team coordination
• Work days and hours as determined necessary or desirable to meet
• Travel to such locations and with such frequency as the plan
determines is necessary or desirable to meet its business needs (if
• Communicate clearly and concisely, both verbally and in writing
including interpersonal skills.
• Utilize computer and appropriate software (e.g., Microsoft
Office: Word, Outlook, Excel, PowerPoint) and job specific
applications/systems to produce correspondence, charts,
spreadsheets, and/or other information applicable to the position
Experience & Education:
• Current, unrestricted Registered Nurse (RN) or Licensed
Vocational Nurse (LVN) license to practice in the State of
California is required.
• 5+ years in the health care industry required.
• 5+ years of varied clinical experience (e.g., Acute Care, Home
• 3+ years of supervisory/management experience in utilization
management activities required.
• Valid driver's license and vehicle, or other approved means of
transportation, an acceptable driving record, and current auto
insurance will be required for work away from the primary office
30% of the time or more.
• Bachelor's degree in Health Care Administration or related field,
or an equivalent combination of education and relevant experience
in the field preferred.
• DHCS, CMS and National Committee Quality Assurance (NCQA)
guidelines and standards related to managed Medi-Cal, Medicare, and
Cal MediConnect lines of business.
• The application of evidence-based guidelines i.e., MCG and/or
• Legislative, regulatory, and quality requirements for health care
service delivery to beneficiaries of the following programs:
Medi-Cal, Healthy Families (HF), Medical Services for Indigents
(MSI), and Medicare.
• Clinical issues related to the successful achievement of quality
• Project management to ensure that numerous goals, objectives, and
detailed actions are properly identified, and their status
• Managed Health Care, Health Care Systems, and Medical
CalOptima is an equal employment opportunity employer and makes all
employment decisions on the basis of merit. CalOptima wants to have
qualified employees in every job position. CalOptima prohibits
unlawful discrimination against any employee, or applicant for
employment, based on race, religion/religious creed, color,
national origin, ancestry, mental or physical disability, medical
condition, genetic information, marital status, sex, sex
stereotype, gender, gender identity, gender expression,
transitioning status, age, sexual orientation, immigration status,
military status as a disabled veteran, or veteran of the Vietnam
era, or any other consideration made unlawful by federal, state, or
local laws. CalOptima also prohibits unlawful discrimination based
on the perception that anyone has any of those characteristics or
is associated with a person who has, or is perceived as having, any
of those characteristics.
If you are a qualified individual with a disability or a disabled
veteran, you may request a reasonable accommodation if you are
unable or limited in your ability to access job openings or apply
for a job on this site as a result of your disability. You can
request reasonable accommodations by contacting Human Resources
Disability Management at .
Job Location: Orange, California
To apply, visit https://apptrkr.com/2400432
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Keywords: CalOptima, Orange , Manager, Utilization Management, Healthcare , Orange, California
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