This position is located in Cypress, CA
Position Summary:The Director of UM has overall responsibility for UM related to all managed groups and Knox Keene activities. Director will be responsible for developing and maintaining and procedure manuals for such activities; responsible for the development of the UM annual work plan/evaluation and quarterly and semi-annual UM reports; for preparation and interaction related to the health plan annual audits for all IPAs/MG, and oversight of daily operations of the UM and denial processes. Director will be responsible for reviewing the processes of clinical areas for process improvement and efficiencies. Position requires knowledge of California Department of Managed Health Care (DMHC) regulations, Federal ERISA regulations, National Committee for Quality Assurance (NCQA) standards, guidelines and Centers for Medicare Services (CMS) and DHS/MediCal standards. The Director will work closely with other clinical departments, Medical Directors and the Chief Executive Officer to ensure that areas of improvement are identified and corrective actions are implemented.Responsibilities:Supervision of UM Case Management and staff; responsible for setting policies, expectations and processes for them and the department.Organizes the pre-authorization process to meet utilization management needs and monitor turn-around times to meet IPA and health plan requirements.Develop, maintain, implement and update the UM programs, including policies and procedures, to meet health plan, NCQA, CMS, DHS and other regulatory standards.Responsible for the timely submission of reports required by Health Plans including the UM plan, quarterly and semi-annual UM reports, 10th of the month reports and any other reports or information required or requested.Responsible for representing Coast in the audits of UM and denial activities and for preparing corrective action plans if requested and for assuring continued delegation status from all Health Plans.Responsible for the denial letter process and compliance thereof.Ensure that the denial process is followed (e.g., determinations for denial are made by the Medical Director, all letters are sent with appropriate language and within the correct time frame).Responsible for supervision of the transplant and CCS Case ManagerResponsible for continued automation of the UM process.Maintains knowledge of current contractual arrangements with Health Plans and Vendors.Monitor UM statistics for over and under utilization and develop programs for maintaining organizational goals.Responsible for the proper and timely response to authorizations received via website; responsible for the glitch reports to ensure all authorizations are processed timely.Responsible for overseeing and reporting on productivity of staff.Oversee preparation of information and attendance at all UM committee meetings. Attendance at QM committee meetings is also required.
Additional Responsibilities:Attend monthly management meetings.Contribute to newsletters as required or requested.Meet with staff at least monthly.Fosters positive interaction and relationships with all internal departments and staff.Prevent and avoid harassment and discrimination. Respond promptly to any complaints in accordance with policy in employee handbook.
MWW#LI-KB1Qualifications:California RN License preferred; LVN LicenseMinimum 5 years management experience in an IPA, Group or Health PlanKnowledge of NCQA, Managed Health Care (DMHC) regulations, Federal ERISA regulations, DHS/Medi-Cal and CMS guidelinesKnowledge of EZ-Cap information system preferredExcellent written, verbal and assessment skillsComputer experience required (MS Word, MS Excel)Analytical and critical thinking skillsCalifornia Drivers LicenseReliable transportation with verification of insurance
Job: Clerical/AdministrativePrimary Location: Lakewood, CaliforniaHospital Location: Coast HealthcareJob Type: Full-timeShift Type: Days
Qualifications: Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status.
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