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Imperial Health Plan of California, Inc. · 1 month ago

Utilization Department Manager, RN (non clinical)

Pasadena, CA

Full-time

Onsite

Mid, Senior Level

$80K/yr - $95K/yr

5+ years exp

Imperial Health Plan of California is a Medicare Advantage provider focused on promoting diversity, equity, and inclusion. The Utilization Department Manager will lead the UM/Prior Authorization Team to ensure compliance with healthcare regulations and standards while facilitating effective collaboration among clinical and non-clinical personnel.

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Responsibilities

Responsible for providing operational leadership to the day to day function of the UM/Prior Authorization Team

The UM Manager will ensure that the team complies with Federal, State, Health Plan and NCQA requirements

Collaborating with clinical and non-clinical personnel providing timely care which complies with generally accepted standards of clinical practice

Assigns work schedules, delegates reviews, provides direction on review priorities, meets the demands of internal and external partners, and ensures staff achieve performance goals and adherence to company policies

Ensures that the UM team is properly trained to conduct medical necessity reviews on incoming pre-service/prior authorization, on routine and expedited referrals requests in compliance with Federal, State, Health Plan and NCQA standards

Ensures UM team documents on the medical management system timely, all supporting clinical information, outreach attempts and criteria used to make a determination

Monitors, tracks, and reports any inappropriate referral patterns to the UM Medical Director and Director of Clinical Services

Serves as a subject matter expert on appropriate use, interpretation and documentation of clinical criteria in the review process using NCD, LCD, Health Plan Medical Guidelines, MCG, NCCN, etc

Facilitates an atmosphere of interactive management and the development of collegial relationships among personnel and others, serving as a link between clinical and the healthcare disciplines

Collaboration with clinical personnel and members of other disciplines, participates in an organizational policy and procedure formulation and decision making, accepts organizational accountability for services provided, and evaluates the quality and appropriateness of care