Sr. Manager, Utilization Management (Sr. Manager II)

at  CalOptima

CALOPTIMA

CalOptima Health is seeking a highly motivated an experienced Sr. Manager, Utilization Management (Sr. Manager II) to join our team. The Sr Manager II (Utilization Management) will be responsible for providing oversight of clinical team treatment authorization compliance and oversight of internal and external health network partners. The incumbent will lead inventory management process improvements for all clinical operation Utilization Management (UM) teams to maximize efficiencies and ensure regulatory compliance and National Committee for Quality Assurance (NCQA) accreditation standard excellence. The incumbent will work collaboratively with the Executive Director, Clinical Operations, Enterprise Analytics team, Medical Director team, health network leadership and oversight of committees to support and coordinate best practice protocols for UM, including communicating and directing protocols across the entire CalOptima Health delivery of care. The incumbent will monitor enterprise utilization, ensure patient access through quality outcomes and use a system approach to ensure whole-person care and communication amongst treatment teams. The incumbent will ensure all UM teams maintain proactive inventory management protocols to serve CalOptima Health members.

MINIMUM QUALIFICATIONS:

• Bachelor’s degree in a health related field required.
• 5 years of UM experience required.
• 5 years in the health care industry required.
• 3 years of supervisory/management experience in management of UM authorization inventory required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
• Valid driver’s license and vehicle or other approved means of transportation, an acceptable driving record and current auto insurance will be required for work away from the primary office 30% of the time or more.

PREFERRED QUALIFICATIONS:

• Master’s degree.
• Current unrestricted Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license to practice in the State of California.

KNOWLEDGE & ABILITIES:

• Develop rapport and establish and maintain effective working relationships with CalOptima Health’s leadership and staff and external contacts at all levels and with diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

PHYSICAL REQUIREMENTS (WITH OR WITHOUT ACCOMMODATIONS):

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
• Lifting and moving objects, patients and/or equipment 10 to 25 pounds

THE SELECTION PROCESS MAY INCLUDE, BUT IS NOT LIMITED TO, A SKILLS ASSESSMENT, PHONE SCREEN AND INTERVIEW.

The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet.
Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application.
CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.
CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.
If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.
To apply, please visit: https://jobs.caloptima.org/jobs/sr-manager-utilization-management-sr-manager-ii-505-city-parkway-california-united-states
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• 50% - Leadership Functions
• Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department.
• Hires, manages, trains, reviews and sets goals for the department and staff.
• Collaborates with clinical operations leadership to align UM protocols, including Behavioral Health and Long-Term Services and Supports to maximize gained efficiencies across programs.
• Facilitates improvement planning and escalation discussions with leadership including, executive team and Chief Medical Officer as appropriate.
• Participates and presents in CalOptima Health’s committee meetings.Promotes a culture of accountability, excellence and continuous improvement with hospital partners through exemplary leadership practices.
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• 45% - Program Oversight

• Contributes to the development of policies and procedures that support effective collaboration for internal UM and external health network partners for UM Program standardization, compliance and excellence.
• Develops and implements effective and standardized communication strategies to facilitate seamless information flow among health care providers.
• Establishes and maintains a strong health network and external clinical team presence, engaging directly with health care providers to understand their challenges and needs priorities and strategic approach to align all CalOptima Health’s UM program and delivery.
• Collaborates with all internal and health network Medical Directors and proactively educates the internal UM department and health network teams as new protocols or requirements emerge related to UM.Participates in workgroups that address UM.
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• 5% - Completes other projects and duties as assigned.