Job Description

Your Role

The Utilization Management Concurrent Review team ensures accurate and timely authorization of designated healthcare services clinical review determinations for Medicare Line of Business. The Manager, Utilization Management Nurse Management will report to the Director, Utilization Management Nurse Management. In this role you will be managing a high functioning team, have direct oversight of day-to-day operations and participate in process improvement/cost of health care initiatives.  Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building, and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work

In this role, you will:

• Establish operational objectives for department or functional area and participate with other managers to establish group objectives 
• Be responsible for team, department, or functional area results in terms of planning and cost in collaboration with department Director 
• Participate in the development and implementation of the annual budget under the direction of department Director 
• Ensure workflow procedures and guidelines are clearly documented and communicated 
• Interpret or initiate changes in guidelines/policies/procedures 
• Manage multiple regulatory reports
• Establish and manage operational reports
• Ensure regulatory and accreditation standards are met for Medicare of business
• Collaborate across functionally to improve member outcomes
• Participate in Regulatory and Internal Audits

Your Knowledge and Experience

• Requires a bachelor's of science in nursing or equivalent experience 
• Requires a current California RN License 
• Requires at least 7 years of prior relevant experience including 3 years of management experience
• Has demonstrated experience with basic management approaches such as work scheduling, prioritizing, coaching, process execution, work organization, inventory management, risk management and delegation
• Requires knowledge of regulatory requirements for all Lines of Business (Medi-Cal, Medicare Advantage and DSNP)
• Requires strong emotional intelligence skills
• Requires the ability to work collaborative with cross functional operations

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