Senior Manager, Utilization Management Operations
Location: Costa Mesa
Posted on: November 16, 2020
OVERVIEW OF POSITION:Responsible for the oversight, management
and optimization of all quality improvement and utilization
management activities. Safeguards that all Utilization Management
(UM) functions are in compliance with regulatory and health plan
standards including policies and procedures across health plans,
NCQA and other regulatory agencies plan standards. Manages staff
directly responsible for the day-to-day operations of the regional
denial unit. Monitors UM processes and functions to ensure proper
use clinically based criteria and health plan specific guidelines,
compliance with turn-around time requirements. Ensures correct
documentation of denial type, the use of accurate grade level and
appropriate denial language using the most current health plan
specific, approved denial templates following the applicable state
and federal requirements. Assists with and coordinates various
quality improvement projects/programs.ESSENTIAL FUNCTIONS:Primary
duties may include but are not limited to:
- Consistently exhibits behavior and communication skills that
demonstrate HealthCare Partners' (HCP) commitment to superior
customer service, including quality, care and concern with each and
every internal and external customer.
- Provides support by presenting quarterly on issues/topics
related to Utilization Management (UM) including delegation,
regulatory requirements, policies, recommendations regarding
compliance and utilization/quality issues related to home health
and/or durable medical equipment.
- Responds in writing to all health plan UM requests and
determines how best to meet these requests.
- Manages, coordinates and facilitates annual health plan audits
of components within the HCP corporate and network organizations.--
Responds in writing to correct any deficiencies.
- Assists and facilitates consistency and compliance of
Utilization Management in accordance with health plan, CMS and NCQA
requirements.-- Assists and makes recommendations for any revisions
to the UM plan to meet these requirements.
- Identify opportunities for improvement in UM processes with UM
Director to develop improvement plans and training programs
- Assists the Regional Utilization Management departments in the
development of the denials process.--
- Reviews and assists Physician Reviewers in composing denial
reasons to ensure the denial reason language is clear and concise
and citing correctly
- Monitors referral turnaround time to meet health plan
- Oversees the processing and submission of all denial letters
region-wide and ensures that denial turnaround times meet health
plan regulatory compliance.
- Develops UM tools to maintain UM and monitor regulatory
- Participates in the development and implementation of
enhancements to the Referral management system.
- Develops and/or updates the Utilization Management departmental
policies and procedures.
- Uses, protects, and discloses HCP patients' protected health
information (PHI) only in accordance with Health Insurance
Portability and Accountability Act (HIPAA) standards.
- Performs additional duties as assigned.EDUCATION:
- Degree from a two-year college/ bachelor's degree
- Graduate from an accredited school of Nursing.
- Current California RN license.EXPERIENCE:Minimum:
- Prior clinical experience preferably in an acute care, clinical
- 3 years of utilization review experience required.
- Knowledge of MGC guidelines
- 3 years management experience, preferably in a medial group /
IPA or HMO setting.Preferred:
- HMO/ Health plan. Experience a plus.
- Previous Medicaid experience a plus
- MGC guideline certification a plusKNOWLEDGE, SKILLS, ABILITIES:
- Computer literate.
- Proficient in Microsoft applications (Word, Excel, PowerPoint,
- Excellent verbal and written communication skills.What's the
first thing that happens when one of the leading independent
medical groups in the country comes together with a global leader
in health care? Opportunity. With--DaVita Medical Group, HealthCare
Partners, The Everett Clinic, Northwest Physicians Network,
MountainView Medical Group and Magan Medical Clinic
joining--OptumCare--and the--UnitedHealth Group--family of
companies, people like you will find increasing levels of
challenge, impact and professional success. We're changing health
care for the better by improving access to affordable, high quality
care, and working together to improve the patient experience. That
takes passion, commitment, intense focus and the ability to
contribute effectively in a highly collaborative team environment.
Are you with us? Learn more about this exciting opportunity to do
your life's best work.(SM)--Careers with OptumCare. Here's the
idea. We built an entire organization around one giant objective;
make the health system work better for everyone. So when it comes
to how we use the world's large accumulation of health - related
information, or guide health and lifestyle choices or manage
pharmacy benefits for millions, our first goal is to leap beyond
the status quo and uncover new ways to serve. OptumCare, part of
the UnitedHealth Group family of businesses, brings together some
of the greatest minds and most advanced ideas on where health care
has to go in order to reach its fullest potential. For you, that
means working on high performance teams against sophisticated
challenges that matter. Here you'll find incredible ideas in one
incredible company and a singular opportunity to do your life's
best work.(SM)--Diversity creates a healthier atmosphere: OptumCare
and its affiliated medical practices are Equal Employment
Opportunity/Affirmative Action employers and all qualified
applicants will receive consideration for employment without regard
to race, color, religion, sex, age, national origin, protected
veteran status, disability status, sexual orientation, gender
identity or expression, marital status, genetic information, or any
other characteristic protected by law. OptumCare and its affiliated
medical practices is a drug-free workplace. Candidates are required
to pass a drug test before beginning employment.
Keywords: Optum, Costa Mesa , Senior Manager, Utilization Management Operations, Executive , Costa Mesa, California
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