Under the direction of the Director, Medical Management this position is responsible for overseeing and managing the day-to-day operations of the Utilization Management Department, health plan delegated activities, and medical management initiatives. Other duties include but are not limited to: staff hiring and retention, performance management, reviewing or gathering of data to promote performance improvement, health plan reporting, and participation in or facilitation of meetings or projects related to departmental functions. This position works closely with the Director of Medical Management & Chief Medical Officer (CMO) to evaluate and monitor medical appropriateness determinations and care coordination activities. This position will require assisting the Director of Medical Management to develop and implement strategic plans which will have a direct impact on cost containment and improved patient outcomes while also collaborating with the Manager of Case Management.
Job Responsibilities/Duties
- Oversees referral/authorizations, denial processes, and correspondence with member and provider
- Responsible for performance improvement monitors
- Reviews DOFR and delegation grids for application in work processes
- Ensures compliance with regulatory requirements and application of clinical decision support criteria for utilization activities deemed by Federal, State and other regulatory and accreditation agencies.
- Performs trouble-shooting when difficult situations arise and takes independent action to resolve
- Assist and help with gathering information for Market Conduct Annual statement (MCAS), MediCare 5-star rating, Corrective Action Plans, Consumer Assessment of Healthcare Providers and Systems (CAHPS), Health Outcome Surveys (HOS).
- Manages special projects, i.e. osteoporosis HEDIS measure, etc.
- Oversees activities of utilization review as applicable to delegated entities which include retro authorizations, retro claims.
- Reviews policies and procedures and desktop procedures annually for regulatory compliance
- Develops desktop procedures and workflows and ensures education is completed
- Monitors and analyzes the productivity and quality of utilization management operations, while providing ongoing feedback and education for the staff.
- Performs audits of utilization management based on health plan compliance needs
- Assist with coordinating delegation oversight audit requests, focus audit requests, and/or corrective action plans
- Works collaboratively with the entire organization to be in a state of continual readiness for Delegation Oversight Audits performed by health plans for various functions
- Uses and/or oversees the use of data analysis and process improvement tools to monitor and improve performance.
- All other duties as assigned, i.e. help with appeal process with AHP
This is an excellent opportunity to work for an organization that truly makes a difference in the community. Clinicas Del Camino Real, Inc. offers a highly competitive salary; excellent benefit package including full medical, dental, vision, life and disability insurance; generous holiday, vacation and sick leave.
Qualifications
- California Registered Nurse with active, unrestricted license or current LVN license issued by the State of California required.
- Bachelor’s degree in Nursing or related healthcare field preferred, plus a minimum of five years’ experience in managed care at the hospital or insurance industry level with at least 1+ year in a supervisory capacity or its equivalent required.
- Experience in managing remote employees preferred.
- Knowledge of State and Federal regulations.
- Functional expertise in utilization management
- Strong knowledge of compliance to regulatory requirements for, MediCal and Medicare plans
- Strong leadership skills with the ability to influence, manage, and motivate personnel.
- Must have analytical ability for problem identification and assessment and evaluation of data/statistics obtained from an on-going review process.
- Capable of resolving escalated issues arising from operations and requiring coordination with other departments.
- Ability to prioritize and multi-task.
- Able to work independently and make independent clinical and non-clinical decisions.
- Excellent communication skills.
- Maintain professional attitude when working with internal and external customers