Managed Care Specialist

Job Summary

The incumbent of this position serves as a Managed Care Specialist (MCS), directly performs first-line utilization management review of outpatient services/care authorizations, preparing authorization cases for RN clinical review and performing non-clinical case/care management functions as directed by RN case managers. The Managed Care Specialist completes a variety of authorization tasks along with providing information to members, clinics, providers an d health plans in a call center style environment. This work is performed as outlined in the department policies and procedures, often independently within narrow guidelines and with decision-making autonomy based on those guidelines. The incumbent will receive direction from the an analyst supervisor and the department manager concerning the overall goals and objectives of the department.

Apply By Date: March 16,2025 at 11:59pm. Selection activities may start at any time.

Minimum Qualifications - For full consideration, applicants are encouraged to upload license and/or certification if required of the position

• Bachelor's degree in related area and/or equivalent work-related experience
• Proficient with use of EPIC
• Proficient with use of window-based computer application (spreadsheets, database management and email systems) and use of system applications such as Outlook, Excel, Word and Adobe
• Knowledge of managed care systems, procedures and regulations.
• Knowledge and understanding of practice patterns, procedures, medical terminology, diagnostic testing and services provided in an ambulatory or institutional setting.
• Knowledge of the referral criteria, service location specifics and complexity of appropriate patient referral direction.
• Proficient with use of electronic medical review.
• Excellent communication and interpersonal skills to interact professionally and compassionately with patients and families while still accomplishing tasks in an efficient manner
• Ability and willingness to establish a good rapport and professional working relationship with all departmental personnel. Ability to maintain appropriate inter-departmental communications.
• Willingness to readily assist co-workers and strive to reduce tension and anxiety among staff members.
• Independent judgment to incorporate established policies and procedures, to improve workload, prioritize assignments and streamline departmental processes.
• Demonstrate strong analytical skills to review all available information, draw conclusions, develop and evaluate alternatives and develop solutions.
• Ability to be diplomatic, informative, courteous and tactful in all contacts with hospital personnel, the public and outside agencies. Demonstrates proficiency and excellence in specific area of conflict management and patient complaint management.
• Knowledge and ability to adhere strictly to HIPAA and privacy guidelines.
• Ability to be flexible and responsive to a rapidly changing workflow.
  
  

Preferred Qualifications

• One (1) year experience in a Managed Care setting
• Prior Authorization experience (HMO preferred)
• Comprehensive knowledge of regulatory agency requirements – Medicare/CMS. NCQA and DMHC.
• Knowledge of health plans’ regulations, policies and contractual carve-outs, such as psychiatry, chiropractic, acupuncture and pharmacy.
• Ability to gather and analyze data, prepare accurate and concise reports and summaries in a comprehensive organized manner.
• Knowledge of the Hospital organizational structure and its impact and relation to the Managed Care Department and departmental goals.
• Knowledge of medical resources in the community and UCDH. Ability to coordinate those resources to appropriately direct the general medical services for Managed Care patients.
• Knowledge and understanding of institutional goals and principles. Ability to learn the dynamics of the organization and must be resourceful and diplomatic when interacting with patients.
• Interpret and represent institutional philosophy, policies, procedure and services provided to the public. Disseminate information regarding programs and services to referring physicians, community groups, members and agencies
• Ability to advocate for the Health System mission and outreach within the community and the University.
  
  

Key Responsibilities

• 50% - Authorization Coordination/Research/Analysis
• 30% - Customer Service
• 5% - Data Management/Report Preparation
• 5% - Customer Satisfaction
• 5% - Education/Training
• 5% - Other Duties
  
  

Department Overview

The Managed Care Utilization Management department includes the combined responsibilities of Utilization Management, Member Services and care coordination, as well as data analytics for auditing compliance with regulatory and contractual metrics for HMO and ACO populations. The department interacts daily with all levels of staff in the ambulatory clinics, both hospital-based and primary care network sites, the Patient Relations and Physician Referral Center staff, multiple community providers and care partners with UC Davis Medical Group and most importantly, members enrolled in the Managed Care HMO Health Plans. The Utilization Management (UM) unit of the department insures services/care rendered to UCDMG capitated members are medically necessarily/appropriate and in conformance clinically with the benefits of the me member's Health Plan.

POSITION INFORMATION

• Salary or Pay Range: $29.16 - $48.97
• Salary Frequency: Hourly
• Salary Grade: 135
• UC Job Title: ADMIN OFCR 2 CX
• UC Job Code: 004263
• Number of Positions: 1
• Appointment Type: Staff: Career
• Percentage of Time: 100
• Shift (Work Schedule): Monday - Friday 8am-5pm
• Location: Health Administrative Services Bldg, Rancho Cordova
• Union Representation: CX-Clerical/Admin
• Benefits Eligible: Yes
• This position is hybrid (mix of on-site and remote work)
• This position is not an H-1B visa opportunity
  
  

Benefits

Outstanding benefits and perks are among the many rewards of working for the University of California. UC Davis offers a full range of benefits, resources and programs to help you bring your best self to work, as well as to help you and your family achieve your health, wellness, financial and career goals. Learn more about the benefits below and eligibility rules by visiting either our handy Benefits Summary for UC Davis Health Employees or Benefits Summary for UC Davis Employees and our Benefits Page.

If you are represented by a union, benefits are negotiated between the University of California (UC) and your union and finalized in a contract. Read your bargaining unit's employment contract, stay abreast of current negotiations and learn about collective bargaining at UC: https://ucnet.universityofcalifornia.edu/labor/bargaining-units/index.html

• High quality and low-cost medical plans to choose from to fit your family’s needs
• UC pays for Dental and Vision insurance premiums for you and your family
• Extensive leave benefits including Pregnancy and Parental Leave, Family & Medical Leave
• Paid Holidays annually as stipulated in the UC Davis Health Policies or Collective Bargaining Agreement
• Paid Time Off/Vacation/Sick Time as stipulated in the UC Davis Health Policies or Collective Bargaining Agreement
• Continuing Education (CE) allowance and Education Reimbursement Program as stipulated in the UC Davis Health Policies or Collective Bargaining Agreement
• Access to free professional development courses and learning opportunities for personal and professional growth
• WorkLife and Wellness programs and resources
• On-site Employee Assistance Program including access to free mental health services
• Supplemental insurance offered including additional life, short/long term disability, pet insurance and legal coverage
• Public Service Loan Forgiveness (PSFL) Qualified Employer & Student Loan Repayment Assistance Program for qualified roles
• Retirement benefit options for eligible roles including Pension and other Retirement Saving Plans. More information on our retirement benefits can be found here
• UC Davis cares about building a community, which is why we provide resources to enhance diversity, equity and inclusion as well as Employee Resource Groups (ERGs) to support our staff
  
  

Physical Demands

• Standing - Occasional Up to 3 Hours
• Walking - Occasional Up to 3 Hours
• Sitting - Frequent 3 to 6 Hours
• Lifting/Carrying 0-25 Lbs - Occasional Up to 3 Hours
• Pushing/Pulling 0-25 Lbs - Occasional Up to 3 Hours
• Bending/Stooping - Occasional Up to 3 Hours
• Squatting/Kneeling - Occasional Up to 3 Hours
• Twisting - Occasional Up to 3 Hours
• Reaching overhead - Occasional Up to 3 Hours
• Keyboard use/repetitive motion - Frequent 3 to 6 Hours
  
  

Mental Demands

• Sustained attention and concentration - Frequent 3 to 6 Hours
• Complex problem solving/reasoning - Occasional Up to 3 Hours
• Ability to organize & prioritize - Frequent 3 to 6 Hours
• Communication skills - Frequent 3 to 6 Hours
• Numerical skills - Occasional Up to 3 Hours
• Constant Interaction - Frequent 3 to 6 Hours
• Customer/Patient Contact - Frequent 3 to 6 Hours
• Multiple Concurrent Tasks - Frequent 3 to 6 Hours
  
  

Work Environment

UC Davis is a smoke and tobacco free campus effective January 1, 2014. Smoking, the use of smokeless tobacco products, and the use of unregulated nicotine products (e-cigarettes) will be strictly prohibited on any UC Davis owned or leased property, indoors and outdoors, including parking lots and residential space.

Special Requirements – Please contact your recruiter with questions regarding which activities apply by position

• This is a critical position, as defined by UC Policy and local procedures, and as such, employment is contingent upon clearing a criminal background check(s) and may include drug screening, medical evaluation clearance and functional capacity assessment
• This position is designated as a mandated reporter under CANRA and UC policy, and employment is contingent on compliance with applicable policies, procedures and training requirements
  
  

Misconduct Disclosure Requirement: As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer.

Diversity, Equity, Inclusion and Belonging

At UC Davis, we’re solving life’s most urgent challenges to bring a fuller, healthier, and more resilient world within reach. We grow from every challenge we take on and we don’t just maintain - we improve. We recognize that creating an inclusive and intellectually vibrant organization means understanding and valuing both our individual differences and our common ground. The most comprehensive solutions come from the most diverse minds and you belong here. As you consider joining UC Davis, please explore our Principles of Community, our Clinical Strategic Plan and strategic vision for research and education, and our latest efforts to outgrow the expected. The University of California, Davis is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age or protected veteran status.

For the University of California’s Affirmative Action Policy, please visit: https://policy.ucop.edu/doc/4010393/PPSM-20

For the University of California’s Anti-Discrimination Policy, please visit: https://policy.ucop.edu/doc/1001004/Anti-Discrimination

Because we want you to be seen, our recruiting process at UC Davis fosters authenticity, diversity, and inclusion. Studies have shown that some people may not apply to jobs unless they meet every single qualification. Each unique role at UC Davis has a set of requirements and you could be perfect for this role, or you could be perfect for the next role! Don’t meet all the requirements? We still encourage you to apply! #YouBelongHere

To learn more about our background check program, please visit: https://hr.ucdavis.edu/departments/recruitment/ucd/selection/background-checks