Description
We are seeking candidates for a Director, Utilization Management role with Prime Health Plan located in Los Angeles CA
Salary: USD $127,000 – $165,000 / yr
Job Summary
The Director, Utilization Management (UM) is directly responsible for the planning, organizational direction, staffing and development of L.A. Care's Utilization Management function(s). The main functions includes but is not limited to in patient, and outpatient utilization review, care transitions, Member and Provider Outreach. As the health plan, the Director of UM also needs to support our contracted delegates when needed. Main responsibility includes: regulatory compliance, accreditation compliance, assistance with oversight of Plan Partners and Delegated Provider Groups related operations, oversight vendor's related delegated functions, operations for direct lines of business and/or management services agreement functions, and interfacing with external agencies including other Local Initiatives, Plan Partners and external organizations. The Director, Utilization Management is further responsible to lead and direct the department to ensure all functions are operating in accordance with the organization's mission, values and strategic goals and are provided in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership. This position is remote, however, you will be required to attend staff meeting at least twice a month if office.
Education Required
Bachelor's Degree in Nursing
Education Preferred
Master's Degree in Nursing
Experience
Required:
At least 7 years experience in implementing and managing of Medicaid and Medicare program requirements with 5-7 years of supervisory/management experience in a health care/health plan environment.
Experience in obtaining and sustaining National Committee for Quality Assurance (NCQA) accreditation.
Preferred:
Experience in Medicare-SNP programs.
Skills Required:
Excellent verbal and written communication skills.
Excellent problem solving, planning, and organizational skills.
Persuasion Skills: Ability to work collaboratively internally and externally to achieve results is critical.
Licenses/Certifications Required
Registered Nurse (RN) - Active, current, and unrestricted California License
Licenses/Certifications Preferred
Required Training
Registered Nurse (RN)
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