Manager, Utilization Management

Manager, Utilization Management San Jose, CA Job Details Full-time $130,622 - $202,465 a year 2 days ago Qualifications Healthcare staff management RN License Regulatory compliance Corrective and preventive actions (CAPA) Mid-level State healthcare regulations CMS regulatory compliance Supervising experience Policy & process development Team management Utilization management NCQA standards Centers for Medicare and Medicaid Services (CMS) Quality systems 2 years Stakeholder relationship building Performance evaluation

Full Job Description About Us:

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans. About the

Role:

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. Day to

Day:

1. Develop, implement and manage all UM processes for continuous and sustained compliance with all applicable state, federal and NCQA regulatory requirements, SCFHP policies and procedures and general business requirements for all lines of business. 2. Develop and implement continuous analysis and quality monitoring of all policies and procedures to evaluate UM staff performance and ensure regulatory compliance, including the development and implementation of effective, measurable corrective action plans to meet targeted strategic outcomes. 3. Ensure the integration of UM operations into other internal and external teams/departments including Quality, Long Term Services and Support (LTSS) and Behavioral Health (BH). 4. Establish and maintain effective interpersonal relationships with all SCFHP staff, members and/or their authorized representatives, providers and other program or agency representatives. 5. Ensure UM Committee preparedness.

About You:

1. Unrestricted professional RN licensure in the state of California. 2. Minimum two years of experience in a supervisory capacity in a managed care setting. 3. Understanding and/or experience with Utilization Management. 4. Must be knowledgeable of

DHCS, CMS, DMHC

regulations and NCQA regulatory Population Health standards. Please review the full job description on our Career's page: https://phf.tbe.taleo.net/phf04/ats/careers/v2/viewRequisition?org=SANTCLAR2&cws=38&rid=3134

Job Type:

Full-time Pay:

$130,622.00 - $202,465.00 per year Application Question(s): Are you knowledgeable of

DHCS, CMS, DMHC

regulations and NCQA regulatory Population Health standards?

Experience:

Supervising:

2 years (Required) Utilization management: 2 years (Required)

License/Certification:

RN License (Required)

Work Location:

Hybrid remote in San Jose, CA 95119