Utilization Management Jobs in California (NOW HIRING)

To provide daily supervision of utilization management staff. Provide departmental leadership, support, resources and direction to staff. Assists in developing and maintaining a cohesive team with a high level of productivity, accuracy and quality to achieve departmental goals and objectives.

• Provides daily leadership, direction, resources, training, evaluation, coverage and program support to assigned staff.
• Performs supervisory functions such as timecard management, staff scheduling to meet business requirements and directing work activities.
• Provides performance feedback to utilization management staff and conducting annual reviews.
• Participates in the interviewing, hiring and on-boarding processes of new staff.
• Maintains active participation with inbound and outbound provider reporting and other related duties, adjusting assignments as necessary to meet business needs and/or regulations.
• Documents and maintains patient-specific records in the Partnership computer system, in databases and files as applicable.
• Participates in committees, workgroups and/or multidisciplinary teams to support Partnership's strategic plan, organizational goals, and/or business needs.
• Facilitates meetings with Partnership community provider partners as a part of utilization management process.
• Develops and maintains positive working relationships with all business partners to ensure
• optimum member care and provider satisfaction.
• Reviews department desktops, policies and procedures, recommends changes for more efficient operations, and communicates changes and updates to staff when appropriate.
• Researches and responds to provider issues or barriers ensuring successful outcomes and superb customer service.
• Audits medical records as appropriate for accuracy, workflow evaluation, staff feedback and process improvement activities.
• This position, in addition to his or her own case load, may be assigned cases in the area of oversight as deemed necessary to provide coverage.
• Evaluates appropriateness of care through interpretation of benefits as outlined in Title 22, Medi-Cal Provider Manual, DMHC CMS regulatory requirements, Partnership Policies and Procedures, and medical necessity criteria for each product line.
• Researches and responds to provider issues or barriers, ensuring successful outcomes and superb customer service.
• Participates in special projects and assignments as required.

Education and Experience

Associate or Bachelor's degree in nursing. RN with 3-5 years'experience to include staff supervision; one (1) year managed care (casemanagement) experience; or equivalent combination of education andexperience. General knowledge of managed care with emphasis in casemanagement preferred.

Special Skills, Licenses and Certifications

Current California RN license. RN Supervisor will be supervising bothRN and LVN staff. Case Management certification preferred. Strongknowledge of nursing requirements in a clinical setting. Knowledge ofutilization management programs as related to use of pre-set criteria andprotocols. Familiarity with business practices and protocols with abilityto access data and information using automated systems. Ability to workwithin an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meetingdeadlines. Strong organizational skills required. Effective telephone andcomputer data entry skills required. Valid California Driver's Licenseand proof of current automobile insurance compliant with Partnership's policiesare required to operate a vehicle and travel for company business.

Performance Based Competencies

Desired competencies (ex: Knowledge of DHCS, Medi-Cal, CMS,medically necessary criteria, CalAIM and/or NCQA regulations. Abilityto work within an interdisciplinary structure and function independentlyin a fast-paced environment while managing multiple priorities anddeadlines. Strong organizational skills required. Computer literacy andproficiency. Excellent written and verbal communication skills inEnglish. Demonstrated experience and ability to build effective workingrelationships and to represent the department effectively in order toaccomplish goals. Ability to manage multiple concurrent projects andmaintain a work pace appropriate to the workload. Ability to assistindividuals in recognizing and solving problems. Ability to supervise,train, motivate, provide guidance to staff.

Work Environment And Physical Demands

Ability to use a computer keyboard. Ability to prioritize workload andinitiate action to acquire needed information from professionals byphone. Ability to function effectively with frequent interruptions anddirection from multiple team members. More than 50% of work time isspent in front of a computer monitor. Must be able to lift, move, or carryobjects of varying size, weighing up to 10 lbs. Some travel required (upto 25%) including occasional overnight.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan's policies and procedures, as they may from time to time be updated. 

HIRING RANGE:

$141,067.17 - $183,387.32

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform.  The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.