Manager, Utilization Management

Communityplans; California, Northern (MO, KY); Hybrid; USD 95,000 - 140,000; Full time

Job summary

Communityplans is seeking a Manager of Utilization Management in California to oversee UM functions, develop policies, and monitor quality. The role supervises the UM Supervisor and ensures compliance with DHCS, CMS, DMHC, NCQA standards and regulatory requirements.

The position requires RN licensure in California, 2+ years supervisory experience in managed care, and strong knowledge of UM processes. Proficiency with Outlook, Word, Excel and case management software is essential.

Qualifications

• RN licensure in California (required).
• Minimum two years in a supervisory role within a managed care setting.
• Understanding and/or experience with Utilization Management (UM).
• Knowledge of DHCS, CMS, DMHC regulations and NCQA Population Health standards.
• Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance.
• Proficient with Outlook, Word, Excel and case management programs.

Responsibilities

• Oversee internal and external delegated UM functions and policy development.
• Supervise the Supervisor of UM to ensure adherence to regulatory and organizational standards.
• Develop and implement procedures, program development and quality monitoring for UM.
• Ensure compliance with state and federal regulations and SCFHP policies.

Skills

RN licensure CA

Supervisory experience

Utilization Management

Regulatory knowledge (DHCS CMS DMHC NC

Accuracy & timeliness

Computer skills (Outlook Word Excel)

Tools

Outlook

Word

Excel

Case management software

Job description

GENERAL DESCRIPTION OF POSITION

The Manager of Utilization Management (UM) is responsible for the direct oversight of internal and external delegated UM functions including the development and implementation of policies, procedures and program development and related quality monitoring. In addition, the Manager of UM is responsible for supervising the Supervisor of UM to ensure that all administrative UM processes are performed in accordance with all applicable state and federal regulatory requirements, SCFHP policies and procedures and business requirements.

REQUIREMENTS – Required (R) Desired (D)

• Unrestricted professional RN licensure in the state of California. (R)
• Minimum two years of experience in a supervisory capacity in a managed care setting. (R)
• Understanding and/or experience with Utilization Management. (R)
• Must be knowledgeable of DHCS, CMS, DMHC regulations and NCQA regulatory Population Health standards. (R)
• Ability to consistently meet accuracy and timeline requirements to maintain regulatory requirements.
• Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs. (R)