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Santa Clara Family Health Plan · 1 month ago

Supervisor, Utilization Management

San Jose, CA

Full-time

Onsite

Mid, Senior Level

$86K/yr - $129K/yr

3+ years exp

Santa Clara Family Health Plan is seeking a Supervisor of Utilization Management responsible for overseeing the daily operations of UM activities. The role includes developing workflows, supervising staff, ensuring compliance with regulations, and serving as a liaison between internal departments and external organizations.

CommunitiesHealth CareInsurance

Comp. & Benefits

Responsibilities

Develop, implement and supervise UM operation workflows to ensure compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures and business requirements for all lines of business

Prepare and analyze operational and regulatory required reports prior to submission

Support internal training efforts, including providing input in the development and implementation of training materials

Monitor workflows and serve as initial point of contact for staff regarding escalation of complex issues; research, troubleshoot and resolve issues using available resources within established guidelines and ensure appropriate resolution, escalation, and/or follow up within specified timeframes. Escalate as appropriate to management

Participate in intradepartmental management team meetings as needed. Frequently strategize with others in Quality, UM, Pharmacy, G & A, and Health Education ensure overall optimal performance of the Health Plan Services department

Serve as the liaison between SCFHP internal departments and outside organizations including, but not limited to hospitals, vendors, and delegated medical groups to resolve authorizations related to eligibility and claims

Identify issues and trends (data, systems, member, provider, other), as well as general departmental questions/concerns; report relevant information and recommendations to management

Follow established Health Services policies and procedures and use available resources to respond to member and/or provider inquiries and resolve concerns in an accurate, timely, respectful, professional and culturally competent manner

Collaborate with the Manager of Utilization Management on routine and ad hoc audits including the development, implementation and monitoring of corrective action plans

Act as back-up to Medical Management Coordinators during times of high volume work and/or staffing shortages to ensure compliance with all applicable state and federal regulatory requirements

Develop effective and professional working relationships with internal and external stakeholders and partners. Communicate effectively with members and providers orally and in writing

Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions

Attend off site meetings or events as necessary

Perform other duties as required or assigned

Recruiting, interviewing, and hiring

Developing a high performing department culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives

Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance

Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees’ needs, ensuring they have the necessary resources to do their work

Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews

Qualification

Utilization ManagementHealthcare knowledgeSupervisory experienceRegulatory complianceInterdisciplinary teamworkCommunication skillsBilingual skillsProblem-solvingTime managementConfidentiality

Required

Associate's Degree in a Healthcare related field, or equivalent experience, training or coursework

Knowledge of health plan benefits, processes and operations related to commercial, Medi-Cal and/or Medicare programs

Minimum three years of experience in managed care or in a health care setting in positions requiring interaction with members and/or providers, two years of which involved progressively responsible experience involving direct Utilization Management responsibilities

Minimum one year of experience in a supervisory or lead capacity

Ability to lead by example and monitor workflows to support the staff by serving as the initial point of escalation regarding the handling of complex issues

Ability to understand, interpret, and apply applicable rules and regulations, and establish and evaluate priorities

Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance

Ability to work within an interdisciplinary team structure

Ability to work weekends and company holidays as needed based on business and regulatory requirements

Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events

Proficient in adapting to changing situations and efficiently alternating focus between telephone and non-telephone tasks to support department operations as dictated by business needs

Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific utilization management programs

Ability to use a keyboard with moderate speed and a high level of accuracy

Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing

Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes

Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position

Ability to maintain confidentiality

Ability to comply with all SCFHP policies and procedures

Ability to perform the job safely and with respect to others, to property and to individual safety

Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time

Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds

Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less

Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment

Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone

Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail