work boldly. live brilliantly.

Utilization Management Manager

Req # 2021-12859

Work Boldly. Live Brilliantly.

Bold decisions and innovative thinking have helped AltaMed, headquartered in Commerce, Calif., become the nation’s largest network of community-based primary care clinics and senior care programs. Some 2,000 professionals in medicine, nursing, social work, mental health rehabilitation, dentistry and health administration assure that we not only provide quality care, but that we do so without exception or regard to ability to pay. We are JCHAO-accredited, and strongly focused on wellness, preventative care and eliminating health care disparities.

Job Description

Under the direction of the Director, Medical Management this position is responsible for overseeing and managing the day-to-day operations of the Utilization Management Department, health plan delegated activities, and medical management initiatives. This position works closely with the Director, Medical Director and VP to evaluate and monitor medical appropriateness determinations and care coordination activities. This position is responsible for developing and implementing strategic plans which will have a direct impact on cost containment and improved patient outcomes.

Qualifications

  1. California Registered Nurse with active, unrestricted license or current LVN license issued by the State of California required.
  2. Bachelor’s degree in Nursing or related healthcare field preferred, plus a minimum of five years’ experience in managed care at the hospital or insurance industry level with at least 1+ year in a supervisory capacity or its equivalent required.
  3. Experience in managing remote employees preferred.
  4. Experience managing projects and initiatives from initiation through completion.
  5. Knowledge of State and Federal regulations required.

Responsibilities

  1. Providers oversight for UM Supervisor and Lead Referral specialist, when applicable
  2. Oversees referral/authorizations, denial processes, and correspondence with member and provider (ie. Denial letters, NOMNC, APTC letters, etc.)
  3. Responsible for management of project templates and performance improvement monitors
  4. Reviews DOFR and delegation grids for application in work processes
  5. Ensures compliance with regulatory requirements and application of clinical decision support criteria for utilization activities deemed by Federal, State and other regulatory and accreditation agencies.
  6. Perform trouble-shooting when difficult situations arise and takes independent action to resolve
  7. Oversees activities of utilization review as applicable to delegated entities.
  8. Reviews policies and procedures and desktop procedures annually for regulatory compliance
  9. Completes desktop procedures and workflows and ensures education is completed
  10. Monitors and analyzes the productivity and quality of utilization management operations, while providing ongoing feedback and education for the staff.
  11. Performs audits of utilization management based on Health Plan Compliance needs
  12. Coordinates with the Compliance Department for Health Plan deliverables: delegation oversight audit requests, focus audit requests, and/or corrective action plans
  13. Works collaboratively with the entire organization to be in a state of continual readiness for Delegation Oversight Audits performed by health plans for various functions Uses and/or oversees the use of data analysis and process improvement tools to monitor and improve performance.
  14. All other duties as assigned

Benefits

AltaMed offers a comprehensive benefits program that recognizes the needs of our diverse employees by supporting their health, security and professional growth.

Wellness

  • Medical/Dental/Vision Plans
  • Voluntary Short-term Disability Plan
  • Long-term Disability Plan
  • Paid Time Off
  • Health Care and Dependent Care Reimbursement Accounts (FSA)
  • Employee Assistance Program (EAP)

Planning Ahead

  • 403 (b) Retirement Plan
  • Life Insurance (Basic & Voluntary)
  • Accidental Death & Dismemberment (Basic & Voluntary)
  • Career Growth and Development
  • Tuition Reimbursement
  • Continuing Education Programs

Other Benefits

  • Employee Reward & Recognition Programs
  • Corporate Employee Discount Programs
  • Wellness Programs

Apply Now

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