Director, Utilization Management

Job Category:  Management/Executive
Department:  Utilization Management
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  5047

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

The Associate Director of Utilization Management (UM) provides direct oversight of staff, operations and special projects.  Works closely with the Director of UM Services and UM Medical Director to assist with meeting the immediate, short and long term goals of the department and organization.  This position is an active member of the UM leadership team, supplying supervision, coaching and problem-solving insight to develop all staff, as well as evaluate the function and competency of UM staff and assigned areas.  Services as a lead on most speciali projects, i.e. Care Catalyst, UM SME, that serve to progress the department and/or the organization.  Will be a SME on UM, Utilization Review (UR) and Compliance.  This role will utilize expertise to ensure that operations meet all of the necessary quality of care delivery standards, appropriate resource utlization, regulatory requirements and timeliness standards.

Duties

General essential functions include responsibility for oversight of staff and staffing, including but not limited to, UM Managers, Supervisors, and Leads to ensure that the day-to-day operations are efficient, accurate, and progressive.

 

Actively participates training, assessment, and evaluation of staff.

 

Ensures that department workflows are current and compliant with industry regulatory standards.  Regularly evaluates the operation for adherence to workflows and monitors productivity, accuracy, and efficiency.

 

Leads, consults, and/or collaborates on special projects that directly or indirectly impact UM.  Develops and maintains collaborative and productive relationships while actively serving as a department liaison with internal and external customers.

 

Provides clinical support and communicates with departmental and administrative staff to facilitate daily department functions, in accordance with regulatory and contractual guidelines and the mission, values and strategic objectives of the health plan.

 

Supports the strategic vision, direction, and goals of the enterprise and the department.

 

Perform other duties as assigned. 

Education Required
Associate's Degree
Bachelor's Degree in Nursing
Education Preferred
Master's Degree in Nursing
Experience

Required:
At least 10 years of experience in implementing and managing of Medicaid and Medicare program requirements with 5-7 years progressive management experience in a health care/ health plan environment.


Experience in obtaining and sustaining NCQA accreditation.

 

Experience in program implementation.

Skills
Licenses/Certifications Required
Registered Nurse (RN) - Active, current and unrestricted California License
Licenses/Certifications Preferred
Certified Case Manager (CCM)
American Case Management Association (ACM)
Required Training
Additional Information

 

L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)


Nearest Major Market: Los Angeles

Job Segment: Medical, Nursing, Registered Nurse, Medicare, Medicaid, Healthcare