Job Summary
The Director III (Utilization Management) is responsible for the oversight, planning, organization, implementation and evaluation of all activities and personnel engaged in Utilization Management (UM) departmental operations. The incumbent provides leadership and direction to the Utilization Management department to ensure compliance with all local, state and federal regulations, accreditation standards are current and all policies and procedures meet current requirements. The incumbent will have oversight of CalOptima s Utilization Management program for CalOptima Community Network, CalOptima Direct and the delegated health networks. The Director III is expected to serve as a liaison for various internal and external committees, workgroups, and operational meetings.
Position Responsibilities
Possesses the Ability To:
- Communicate clearly and concisely, both orally and in writing.
- Proactively present outcomes, barriers remediation and strategy to Executive level leadership.
- Work in an extremely fast-paced environment with multiple competing priorities and matrix reporting relationships.
- Make decisions in a timely manner and clearly communicate to all organizational levels at both a vertical and horizontal manner.
- Present statistical and technical UM data in a clear and understandable manner utilizing appropriate visual aids.
- Effectively supervise and coordinate the work of workgroups engaged in quality improvement activities.
- Communicate findings of utilization reports to providers and internal or external stakeholders.
- Have strong clinical skills.
- Present data and information to a wide range of groups using a variety of delivery methods.
- Establish and maintain effective working relationships with CalOptima leadership and staff.
- Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Requirements
Experience & Education:
- Bachelor s degree required.
- Current, unrestricted Registered Nurse (RN) License to practice in the State of California required.
- 7 years of utilization management experience in a managed care environment required; preferably with Medicare and Medicaid populations.
- 5 years of experience in a supervisory role required.
- An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
Preferred Qualifications:
- Master s degree preferred.
Knowledge of:
- California Medi-Cal and Medicare benefits, regulations and standards.
- Hierarchical clinical criteria, MCG and custom Managed Care Medical Policy
- National Committee for Quality Assurance (NCQA) and CMS standards, Quality Improvement studies, Healthcare Effectiveness Data and Information Set (HEDIS) reporting.
- Data collection and analysis, and management practices as related to quality of medical care.
Benefits
At Sunshine Enterprise USA LLC, we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:
Competitive pay & weekly paychecks
Health, dental, vision, and life insurance
401(k) savings plan
Awards and recognition programs
Benefit eligibility is dependent on employment status.
Sunshine Enterprise USA is an Equal Opportunity Employer Minorities, Females, Veterans and Disabled Persons
Experience & Education: Bachelor s degree required. Current, unrestricted Registered Nurse (RN) License to practice in the State of California required. 7 years of utilization management experience in a managed care environment required; preferably with Medicare and Medicaid populations. 5 years of experience in a supervisory role required. An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying. Preferred Qualifications: Master s degree preferred. Knowledge of: California Medi-Cal and Medicare benefits, regulations and standards. Hierarchical clinical criteria, MCG and custom Managed Care Medical Policy National Committee for Quality Assurance (NCQA) and CMS standards, Quality Improvement studies, Healthcare Effectiveness Data and Information Set (HEDIS) reporting. Data collection and analysis, and management practices as related to quality of medical care.