Utilization Management Director jobs in Long Beach, CA

Utilization Management Department operations: The Manager is responsible for ongoing management and oversight of all components of the pre-service, and concurrent requests for care for IPA members, to ensure timely and appropriate care is provided. This position works closely with the Chief Medical Officer and UM Medical Director to ensure physician review for medical necessity denials are supported by adherence to governmental and health plan criteria and guidelines both from a clinical perspective and an administrative perspective addressing all elements of the review process. This position also works closely with the Director of Compliance to ensure all components of the health plan delegated functions and relevant Utilization Management requirements are met.

Primary Duties and Responsibilities:

• Lead and manage all aspects of Utilization Management Department operations
• Oversee department compliance with regulatory requirements of local, state, federal, and private agencies
• Establish, maintain, and achieve department goals that are aligned with IPA initiatives, including but not limited to established turn-around time requirements
• Work with physician reviewers and committees to ensure timely, high quality, cost effective care for IPA Members
• Oversee and direct department staff to ensure established performance standards are met
• Develop and administer effective training programs and materials, to ensure all staff are prepared and qualified to perform their job requirements.
• Providing day-to-day leadership to and management of department staff
• Ensuring that all department policies and procedures are current, effective and consistent with regulatory requirements
• Accountable for the development and review of the Utilization Management annual, quarterly and semi-annually UM work plans
• Following established guidelines, prospectively and retrospectively evaluate the medical necessity, appropriateness, and efficiency of medical services and procedures provided to IPA members (Commercial, MA, and Duals)
• Based on audit findings, internal review of processes and outcomes, and any additional sources of information, direct, draft and conduct additional training and follow-up audits to ensure compliance with areas of improvement, new processes and requirements and any remedial requirements.
• Stays current with applicable regulatory requirements for all UM operations
• Ensure processes are supported with education, training, Policies and Procedures and appropriate Job Aids as needed
• Continually update and circulate Job Aids as needed
• · Coordinates cost effective care supported by clinical practice guidelines
• Accurately and comprehensively ensure that all Utilization Management decisions are based on standards of practice and established guidelines, and in compliance with IPA policies and procedures and regulatory requirements
• Act as a resource for IPA and providers and office staff regarding issues relating to the Utilization Management Department
• Interact and communicate with multidisciplinary teams to ensure continuity and coordination of Members' care
• Prepare regular monthly management reports
• Other duties as assigned

Educational Requirements:

• Current, unrestricted California RN license
• B.S.N. degree required
• Master’s degree preferred

Experience Required:

• Five (5) to seven (7) years’ managed care experience in the health plan or delegated medical group environment
• Minimum three (3) years experience in California HMO utilization management in managed care organization or delegated medical group environment
• Minimum three (3) years’ management level experience, including managing direct reports
• Demonstrated ability to lead high-performing teams
• Health plan audit experience strongly preferred
• Experience working with requirements of Centers for Medicare & Medicaid (CMS), Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS) regulations, and National Committee on Quality Assurance (NCQA).

#24037

Job Type: Full-time

Pay: $133,557.00 - $228,946.00 per year

Benefits:

• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

License/Certification:

• RN (Required)

Work Location: In person