Utilization Management Manager - Adult Programs

Description

Central Coast Salary Range: $117,904 - $176,857 Annually

Job Summary

The Utilization Management Manager is a Registered Nurse responsible for planning, organizing, and overseeing the daily operations within the Medical Management department and the Health Services division. This role provides leadership, guidance, and support, ensures program descriptions, policies, and procedures are current, and participates in special assignments, audits, and focus projects. Additional related duties are performed as assigned.

Duties and Responsibilities

• Plan, develop, and manage UM or CM activities, projects and initiatives as assigned.

• Contribute to the creation and implementation of effective standards, policies, protocols, processes, workflows, and reports.

• Participate in both internal and external audits.

• Analyze and prepare periodic reports on UM or CM activities, as assigned.

• Assess the effectiveness of health plan-wide UM or CM activities.

• Identify and address process issues related to UM or CM activities and functionality.

• Serve as the subject matter expert for UM or CM-related activities.

• Collaborate with IT to  , work on electronic UM platform, improve functionality, and generate reports.

• Provide guidance to providers and members regarding timely requests, authorization requirements, and UM or CM related matters.

• Act as the liaison between the organization, community agencies and providers.

• Provide clinical input for various projects and programs within the Health Services Department.

• Ensure the unit meets departmental, regulatory, and contractual compliance goals.

• Serve as a liaison to both internal and external customers to ensure prompt issue resolution.

• Monitor staff productivity and ensure compliance with organizational standards.

• Assist with claims review as assigned.

• Measure and report on the consistent application of UM criteria.

• Participate in agency committees.

• Act as a liaison between Medical Management and UM delegates to facilitate communication through meetings and monitoring of the delegates’ compliance to UM standards.

• Perform other duties as assigned.

Qualifications

Knowledge/Skills/Abilities

Required:

• Knowledge of current principles and practices in managed care and health plan regulatory requirements as they apply to the assigned unit.

• Ability to collaborate effectively with both internal and external customers, including programs within the Health Services department, i.e. Pediatric UM, Care Management, Behavioral Health, D-SNP, Pharmacy, and Enhanced Care Management

• Strong ability to plan, direct, and coordinate activities for a large team.

• Skilled in mentoring and assisting in the development of leads and supervisors.

• Capable of counseling and addressing performance issues with low performers.

• Ability to take a leadership role in initiating activities, communication, and projects.

• Proficient in preparing accurate records and reports within established timelines.

• Strong verbal and written communication skills, including presentation abilities.

• Proficient in Microsoft Word, Excel, and PowerPoint.

• Depending on the unit assignment, knowledgeable of UM and/or CM standards of practice and their relation to health plan activities.

Education and Experience

Required:

• Active and unrestricted California RN license.

• Associate degree in Nursing.

• Five (5) years of experience in medical management within a managed care setting, with at least two (2) years at a supervisory level or higher, which may substitute for a bachelor’s degree.

• A minimum of three (3) years of experience in medical management within a managed care environment.

Preferred:

• Experience in Medi-Cal managed care is preferred.

• Bachelor’s degree in Nursing is preferred.

Salary : $117,904 - $176,857