Manager, Utilization Management (UM Oversight & Clinical Administration)
Job Description
Department(s): Utilization Management (Delegate Monitoring)
Reports to: Director, Utilization Management
FLSA status: Exempt
Salary Grade: P - $117,000 - $192,390
Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on
Tuesday, March 5, 2024 at 11:59 PM. Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. About CalOptima HealthAre you looking for a career that changes lives? As the single largest health plan in Orange County, CalOptima Health serves one in three residents with health insurance programs for low-income children, adults, seniors and people with disabilities. Our 1,500 employees are valued for their individual perspectives and contributions and benefit from flexible work schedules, recognition and opportunities to grow. If you're looking for a rewarding career supporting a meaningful mission, along with generous benefits and recognition, consider joining us at CalOptima Health!
About the PositionThe Manager, Utilization Management (UM Oversight & Clinical Administration) will provide direct management and coordination activities for Utilization Management (UM) program compliance and delegated health network oversight, to ensure that service and compliance standards are met, and operations are consistent with all regulatory requirements, accreditation standards and CalOptima Health's policies and procedures. The incumbent will be responsible for staying updated on regulatory requirements from All Plan Letters (APLs), CCS Number Letters (NLs) and regulatory changes for the management of and to ensure adherence to CalOptima Health's internal UM department and external health network's UM operations. The incumbent will work closely with key internal and external stakeholders relevant to the UM (outpatient and inpatient) program and delivery of care across CalOptima Health.
Duties & Responsibilities: - Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
- Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department.
- Manages the day-to-day activities of the Clinical Administrative and Oversight team in UM to ensure compliance with regulatory requirements, accreditation standards and CalOptima Health's policies.
- Interviews, onboards, trains, manages, motivates, supports and evaluates staff.
- Develops clinical and documentation tools for education and oversight of the UM Operational team and sets performance standards for the Clinical Administrative and Oversight team.
- Establishes and maintains priorities and strategic approach to meet internal and external deadlines for regulatory and programmatic procedures to support UM team compliance.
- Collaborates with the Medical Director and Director of UM to ensure appropriate monitoring of the internal UM team and delegated health network performance and proactively educates the internal UM department and Health Network teams as new requirements and regulatory changes emerge.
- Researches and informs health network delegates and CalOptima Health's internal UM teams of any regulatory or programmatic changes in requirements.
- Participates in workgroups that address both clinical and non-clinical internal activities in which CalOptima Health 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.
- Participates and attends CalOptima Health's Delegation Oversight Committee (DOC) meetings and Internal Audit meetings.
- Presents monitoring findings at the Utilization Management Committee (UMC) and other committees as requested.
- Ensures all reviews for medical appropriateness use the established criteria to determine the medical necessity of the request.
- Demonstrates support of CalOptima Health's goals and priorities with attention to managing department monitoring activities that are cost-effective in terms of resources, materials and time.
- Leads the annual review and revision of CalOptima Health's policies and procedures and UM department desktop procedures as required by benefit plan changes guidance from CMS and DHCS and department process improvement workflow updates.
- Assists the Director of Utilization Management in all areas of the department, as requested, to ensure department and organizational goals are met.
- Completes other projects and duties as assigned.
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.
- An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
- 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.
Physical Demands and Work Environment:The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Physical demands: While performing duties of the job, employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers for typing on the computer and using the mouse. Employee must be able to communicate, particularly for regular phone use, in meetings, and face-to-face interaction. This position is required to work to project timelines, and at times may deal with significant time pressures.
Work Environment: Typical office environment with minimal noise levels and controlled office temperatures.
About our Benefits & Wellness options:At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.
CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health 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 Health 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. Job Location: Orange, California
Position Type:
To apply, visit
https://jobs.silkroad.com/CalOptima/Careers/jobs/4548
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