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Manager, Utilization Management

Company: CalOptima
Location: Orange
Posted on: November 16, 2021

Job Description:

Other opening in Orange, California. This and other nursing administrator jobs brought to you by

Manager, Utilization Management

Job Description

Department(s): Utilization Management (Delegate Monitoring)
Reports to: Director, Utilization Management
FLSA status: Exempt
Salary Grade: P - $117,000 - $165,000

Job Summary

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.

Position Responsibilities:

• 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 evaluates staff.
• 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 UM team.
• 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 senior staff.
• Educates CalOptima staff and health networks on compliance/regulatory initiatives.
• 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 request.
• 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 environment.
• 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 objectives.
• Demonstrate and motivate others in effective team coordination and cooperation.
• Work days and hours as determined necessary or desirable to meet business needs.
• Travel to such locations and with such frequency as the plan determines is necessary or desirable to meet its business needs (if travel required).
• 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 assignment.

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 Care) required.
• 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.

Preferred Qualifications:

• Bachelor's degree in Health Care Administration or related field, or an equivalent combination of education and relevant experience in the field preferred.

Knowledge of:

• 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 InterQual Guidelines.
• 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 improvement initiatives.
• Project management to ensure that numerous goals, objectives, and detailed actions are properly identified, and their status monitored.
• Managed Health Care, Health Care Systems, and Medical Administration.

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

Position Type:

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Keywords: CalOptima, Orange , Manager, Utilization Management, Healthcare , Orange, California

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