Utilization Management Manager, Medicare Advantage - RN

Description

Take on a high-impact role within a world-class health organization. Help drive the continued delivery of exceptional patient care. Take your career to the next level. You can do all this and more at UCLA Health.

As a Manager for Medicare Advantage Utilization Management, you’ll provide direct management to a team of UM coordinators and nurses. You’ll work closely with Medicare Advantage leadership to plan, execute, and manage various initiatives related to UM administrative, operational, and strategic objectives. You’ll demonstrate leadership and effective communication by fostering collaborative relationships with peers, co-workers, and staff. You’ll be responsible for overseeing and coordinating the following major functions:

• Pre-service Authorizations/Denial Letters
• Concurrent Review
• Continuity of Care
• Retro Claims
• Retrospective Review
• Referral Automation Business Rules/Configuration

Salary Range: $116,300 - $264,600 Annually

Qualifications

We’re seeking a self-motivated, detail-oriented, service-driven leader with:

• Current unrestricted RN licensure in CA required
• Bachelors of Science, Nursing (BSN) degree required
• Five or more years of utilization management required
• Four or more years of managerial experience required
• Four or more years of clinical experience providing direct patient care
• experience in an HMO environment
• Thorough knowledge of health care industry, utilization review, utilization management, and concurrent review ACM/CCM preferred
• Knowledge of Health Plan, DMHC, CMS, HIPPA and NCQA requirements
• Familiarity with CPT-4, ICD-10, and HCPCS codes
• Proficient computer skills including Internet search capabilities, Microsoft Word, Excel and Managed Care software (i.e. EZ Cap, Diamond, IDX)
• Strong critical thinking, problem solving, and analytical skills
• Excellent communication, organizational, and prioritizing skills required
• Ability to develop, implement, and evaluate methods and systems to improve efficiency
• Ability to lead and facilitate cross-functional workgroups and other meetings
• Skill in working with complex organizations to comply with regulatory requirements
• Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, health plan requirements and State/Federal regulations
• Ability to analyze and organize complex federal and private insurance regulations
• Ability to travel/attend off-site meetings and conferences
• ACM - Accredited Case Manager preferred
• CCM - Certified Case Manager preferred

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At UCLA Health, you can help heal humankind, one patient at a time by improving health, alleviating suffering and delivering acts of kindness. As you do, you’ll achieve great things in your life and your career. We’re a world-class health organization with four hospitals consistently recognized among the nation’s very best as well as an internationally-renowned medical school, primary and specialty care clinics and much more. Within our dynamic, innovative and growing organization, you’ll find exceptional opportunities to make the most of your abilities in a supportive, empowering and inclusive environment. If you embrace our values of Integrity, Compassion, Respect, Teamwork, Excellence and Discovery we invite you to see all you can accomplish at UCLA Health.

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