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Manager, Utilization Management

Rancho Cordova, CA

Position: Project Management

Job Description

Contract-to-hire.

Position Purpose:
Perform duties to conduct and manage the day to day operations of the utilization management function. Communicate with staff to facilitate daily department functions.

Responsibilities:

  • Queue Management
  • Will need to help improve turnaround times, ensure cases are being met, performing quality reviews (looking at nurses documentation and process to ensure that they are being done and being done well)
  • Some process improvement required (working w/managers on non-clinical side to develop improvements & how things flow back and forth between the team)
  • Participate in Meetings with vendors and be able to report out on meetings
  • Review analyses of activities, costs, operations and forecast data to determine progress toward stated goals and objectives.
  • Promote compliance with federal and state regulations and contractual agreements.
  • Develop, implement and maintain compliance, policies and procedures regarding medical utilization management functions.
  • Develop, implement, and maintain utilization management programs to facilitate the use of appropriate medical resources and decrease the business unit's financial exposure.
  • Compile and review multiple reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management.
  • Facilitate on-going communication between utilization management staff and contracted providers.
  • Develop staff skills and competencies through training and experience. Available to non-clinical staff as a resource for clinical questions.
  • This manager will be overseeing the Appeals and grievances (provider and member) team, total 15-20 staff. There is one supervisor and one lead in the team. The supervisor has 15- 20 nurses that report to her.
  • At this time we are all remote. Once we have entirely transitioned into the office, expectation and the department expectation is that you report to our office.
  • Must live in the Sacramento area office area

Education/Experience:

  • Bachelor’s degree in related field or equivalent experience. Bachelor’s degree in nursing preferred.
  • Case Management Certification preferred.+ years utilization management and recent nursing experience in an acute care setting particularly in medical/surgical, pediatrics, or obstetrics and management experience.
  • Thorough knowledge of utilization management and clinical nursing. Familiarity with Medicare and Medicaid managed care practices and policies, CHIP and SCHIP.
  • Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.

Location: Sacramento Remote - Must live in the Sacramento area as you will be in office after the stay-at-home orders are lifted.

Meet Your Recruiter

Tarah Dionisio
Recruiter

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