Gold Coast Health Plan will not sponsor applicants for work visas.
The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California.
POSITION SUMMARY
Under the direction of the Utilization Management Director, the Manager, Utilization Management, position is responsible for the implementation, evaluation and oversight of programs and functions that directly impact the cost and quality of the care to Gold Coast Health Plan members, including the monitoring and improvement of efficiency and outcomes of the UM Program. This position manages and directs a team of professional nurses, social workers, and support staff that perform the daily operations of all UM staff activities, including Prior Authorization, Concurrent Stay Review, Discharge Planning, Grievances and Clinical Appeals.
Additionally, this position identifies and implements process improvement in workflows with the goal of using evidence-based criteria to assure care is medically indicated, andindicated and provided in the appropriate setting at the appropriate time.
This position is differentiated from other Manager positions in the organization by the large staff of Registered Nurses, Social Workers, and Support staff that manage the UM functions at GCHP.
Work Schedule: Travel; work protracted and irregular hours and evening meetings, or work unusual hours for meeting attendance or participation in specific projects or programs.
ESSENTIAL FUNCTIONS
Reasonable Accommodations Statement
To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.
Essential Functions Statement(s)
- Interview, hire, orient, train, develop and motivate a professional and support staff to achieve the organization's mission and strategic plan objectives; recruit talented RNs, train physician reviewers, and motivate staff to meet results while striving to be the employer of choice and retain staff.
- Establish and update local policies and procedures to ensure effective efficient operation of responsibilities of utilization management and quality functions
- Prepare, conduct and document staff performance plans and evaluations; provide timely and constructive feedback on performance and document all corrective counseling with staff.
- Conduct and report results of annual UM Inter Rater Reliability Testing
- Supervise and coordinate the activities of professional and support staff to ensure adequate staffing, workloads and monitoring of paid time off; organize the department workload and establish work standards to ensure efficiency and productivity; make recommendations for staffing levels.
- Establish and maintain effective working relationships with public and private agencies and vendors; work closely with contracted hospitals and other network partners, including community-based organizations.
- Responsible for personnel functions, including, but not limited to, employee performance review, quality audits, hands-on training and education for team members, conflict resolution and assessment and refinement of workflows and processes.
- Participate in various committees and meetings and prepare management / data reports to communicate activities and cost effectiveness of the department.
- Strive to reduce medical costs utilizing UM strategies and industry best practices including the identification and implementation of interventional measures when indicated.
- Maintain confidentiality and privacy of member information at all times, in accordance with applicable laws and regulations.
- Adhere to all organizational employee policies and procedures, and meet required performance standards.
POSITION QUALIFICATIONS
Competency Statement(s)
- Management Skills - Ability to organize and direct oneself and effectively supervise others.
- Business Acumen - Ability to grasp and understand business concepts and issues.
- Adaptability - Ability to adapt to change in the workplace.
- Change Management - Ability to encourage others to seek opportunities for different and innovative approaches to addressing problems and opportunities.
- Customer Oriented - Ability to take care of the customers’ needs while following company procedures.
- Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.
- Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.
SKILLS & ABILITIES
Education: Bachelor's Degree (four year college or technical school) Required, Field of Study: BSN in Nursing or other related health care field
An active, unrestricted California Registered Nurse license: Required
Experience: 3 years of paid experience in a managed Medi-Cal environment
2 years of paid supervisory experience in UM- preferred
Computer Skills: Advanced skills included in the MS Office products.
Certifications & Licenses: A valid, unrestricted, and active California Registered Nurse license.
Other Requirements: Demonstrated expertise and ability in the following areas as evidenced by experience is required:
- Knowledge of current standards of practice of UM (CA State regs);
- Knowledge of managed care issues (including benefits and contract limitations, delivery and reimbursement systems), and role of medical management activities;
- Ability to comprehend, interpret and apply in timely manner complex policies, medical criteria and guidelines in relation to member benefits;
- Knowledge of all UM policies and procedures; ability to clearly and effectively communicate and negotiate with members and families, physicians, and other health care providers;
- Self-motivated to seek knowledge in order to improve personal and professional performance;
- Ability to influence and work effectively in a cross-functional team environment.