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Partnership HealthPlan of California · 2 days ago

Supervisor of Utilization Management

Fairfield, CA

Full-time

Onsite

Mid, Senior Level

$136K/yr - $177K/yr

3+ years exp

Partnership HealthPlan of California is seeking a Supervisor of Utilization Management to provide daily supervision and leadership to the utilization management staff. The role involves overseeing staff performance, managing operations, and ensuring compliance with healthcare regulations while fostering a productive team environment.

Health CareInsuranceNon Profit

Culture & Values

Responsibilities

Provides daily leadership, direction, resources, training, evaluation, coverage and program support to assigned staff

Performs supervisory functions such as timecard management, staff scheduling to meet business requirements and directing work activities

Provides performance feedback to utilization management staff and conducting annual reviews

Participates in the interviewing, hiring and on-boarding processes of new staff

Maintains active participation with inbound and outbound provider reporting and other related duties, adjusting assignments as necessary to meet business needs and/or regulations

Documents and maintains patient-specific records in the Partnership computer system, in databases and files as applicable

Participates in committees, workgroups and/or multidisciplinary teams to support Partnership’s strategic plan, organizational goals, and/or business needs

Facilitates meetings with Partnership community provider partners as a part of utilization management process

Develops and maintains positive working relationships with all business partners to ensure optimum member care and provider satisfaction

Reviews department desktops, policies and procedures, recommends changes for more efficient operations, and communicates changes and updates to staff when appropriate

Researches and responds to provider issues or barriers ensuring successful outcomes and superb customer service

Audits medical records as appropriate for accuracy, workflow evaluation, staff feedback and process improvement activities

This position, in addition to his or her own case load, may be assigned cases in the area of oversight as deemed necessary to provide coverage

Evaluates appropriateness of care through interpretation of benefits as outlined in Title 22, Medi-Cal Provider Manual, DMHC CMS regulatory requirements, Partnership Policies and Procedures, and medical necessity criteria for each product line

Researches and responds to provider issues or barriers, ensuring successful outcomes and superb customer service

Participates in special projects and assignments as required

Qualification

California RN licenseCase Management certificationManaged care experienceUtilization management knowledgeNursing requirements knowledgeComputer literacyInterdisciplinary teamworkSupervisory skillsOrganizational skillsEffective communication skills

Required

Associate or Bachelor's degree in nursing

Current California RN license

RN with 3-5 years' experience to include staff supervision

One (1) year managed care (case management) experience

Strong knowledge of nursing requirements in a clinical setting

Knowledge of utilization management programs as related to use of pre-set criteria and protocols

Familiarity with business practices and protocols with ability to access data and information using automated systems

Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meeting deadlines

Strong Organizational Skills Required

Effective Telephone And computer data entry skills required

Valid California Driver's License and proof of current automobile insurance compliant with Partnership's policies are required to operate a vehicle and travel for company business

Excellent written and verbal communication skills in English

Demonstrated experience and ability to build effective working relationships and to represent the department effectively in order to accomplish goals

Ability to manage multiple concurrent projects and maintain a work pace appropriate to the workload

Ability to assist individuals in recognizing and solving problems

Ability to supervise, train, motivate, provide guidance to staff

Preferred

General knowledge of managed care with emphasis in case management preferred

Case Management certification preferred

Desired competencies (ex: Knowledge of DHCS, Medi-Cal, CMS, medically necessary criteria, CalAIM and/or NCQA regulations

Company

Partnership HealthPlan of California

Partnership HealthPlan of California is a non-profit community-based health care organization that contracts with the state to administer Medi-Cal benefits through local care providers to ensure Medi-Cal recipients have access to high-quality comprehensive cost-effective health care.

Founded in 1994

Fairfield, California, USA

1001-5000 employees