Utilization Management Manager

This position is responsible for providing a clinical leadership role to the Medical Management Department by managing the day-to-day clinical and operational functions, ensuring adherence with operational policies, procedures and regulatory requirements. Oversees audits of the Medical Department by regulatory agencies as well as audits for several health plans for delegated UM functions and develops and monitors corrective action plans.

1. Provides clinical leadership and management to the UM department by managing the day-to-day operational functions.
2. Analyzes UM data to identify trends and recommend interventions to the Medical Director. Accountable for utilization management metrics and reporting to the QI Committee.
3. Assesses clinical and operational policies and procedures annually; revises and implements as appropriate.
4. Seeks to continually improve clinical and operational processes to enhance departmental accuracy and efficiency.
5. Works with the finance and claims department to improve processes for claims adjudication and accuracy.
6. Conducts quality improvement activities for clinical and administrative/operational processes in the UM department such as turnaround times for authorizations, denial letters and member notification of services etc.
7. Develops resource tools and conducts training to educate the clinical and administrative staff in the many aspects of clinical, delegated functions and operational policies and procedures at least annually to ensure staff competence.
8. Monitors ongoing compliance with state and federal requirements for the UM department and implements actions to correct issues, improve and maintain compliance.
9. Serves as primary liaison with all of Jade Health Care Medical Group’s contracted health plans; responsible for managing all aspects of the annual and intermittent audits and corrective action plans. Manages relationships with health plan auditors and ensures quarterly reports are timely and all information received from plans is implemented into UM processes.
10. Prepares for and manages regulatory audits and responds to departmental inquiries from the DMHC and CMS. Serves as UM liaison with all state and federal agencies; responsible for managing all aspects of the periodic audits and corrective action plans.
11. Conducts annual employee evaluations for clinical and non-clinical staff in the department.
12. Performs other duties as assigned by the Medical Director.

• An active CA Registered Nurse license with a minimum of a Bachelor’s degree or equivalent experience
• Five years supervisory experience, including hiring, developing staff, and conducting performance evaluations
• Five years prior experience in managed care environment within the areas of UM.
• Good knowledge of current regulatory UM standards (i.e. DMHC, Medicare, and Medicaid regulations).
• Proficiency in InterQual Criteria.
• Excellent verbal and written communication skills.
• Ability to develop and deliver presentations.
• Flexibility, adaptability, problem solving capability, creativity, initiative, teamwork and the ability to work with a broad range of constituencies.
• Strong customer service orientation. Ability to establish and maintain productive business relationships, manage conflict and negotiate solutions.
• Initiative, time management and organizational skills, including the ability to prioritize concurrent projects and activities, meet deadlines and work under time constraints.
• Excellent time management, organizing and coordinating skills.
• Ability to make management decisions and judgments on sensitive and confidential issues.
• Ability to work independently, set and change priorities quickly and as the situation warrants.
• Strong skills in Microsoft applications including MS Office and Excel.

• Able to lift up to 30 pounds
• Use proper body mechanics when handling equipment
• Standing, walking and moving 50% of the day.

Complies with CCHP Compliance Handbook including Code of Ethics and all statutes, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs.

Starting at $111,000 – $151,000 per year

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.