Manager, Medical Management

Job Summary

The Manager of Medical Management is responsible for the overall day-to-day operations of the staff and activities requiring clinical licensure in the Utilization Management (UM) department. This position will work closely leaders to develop and organize the department’s work priorities and deliverables. This position will manage clinical personnel to orchestrate and oversee the completion of tasks requiring clinical determinations. This position will also be responsible for internal and external reporting, and managing the monthly data needed to ensure department metrics are met or exceeded, including but not limited to, productivity, and satisfaction of internal and external customers.

The Manager of Medical Management will also work closely with other LA Care Leaders to ensure that work is being completed accurately and timely. This position will collaborate with interfacing departments to ensure that consistent application of clinical criteria, quality of work, and productivity is maximized. This position will also lead team meetings, develop the UM clinical staff, represent the UM Clinical unit at meetings when applicable, and escalate issues as appropriate. This position manages all aspects of running an efficient  team, including hiring, supervising, coaching, training,  disciplining, and motivating direct-reports.

Duties

Oversees and monitors operational compliance with organizational standards, policies and procedures and regulatory requirements. Develops and implements approved departmental policies and procedures/workflows. Implements and monitors departmental performance standards.  Performs ongoing monitoring and evaluation of departmental operations to assure optimal efficiency and effectiveness.

Collaborates with department leadership to establish operational objectives for the business unit.

Works with members of cross-functional teams to glean and provide information pertinent to operational goals and acts as an expert resource.

Manage staff , including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.

Ensures timely and accurate submission of reports/documents to organizational leaders and regulatory agencies.

Assures appropriate department interface with key internal and external stakeholders.

Participates in the development of and is responsible for the implementation of operational business plans and departmental objectives to support organization strategies.

Contributes to departmental statistical, quality and performance reports.

Develops and maintains effective communication mechanisms at various levels of the organization and with external organizations.

Provides input for the departmental budgets.

Leads various committees and workgroups.

Assures the maintenance of positive relationships with other departments, PPGs, other Local Initiatives and Community Based Organizations.

Implements, with approval, programs that improve the provision of services to members.

Manages content for PPG trainings/JOMS. Responsible for oversight and adequate performance of direct line of business PPG delegated activities. Work with department leadership for enhancements as necessary. Develops and sustains active communications with PPGs.

Provide administrative oversight of the L.A Care After Hours programs.

Actively participates in regulatory audits.

Performs other duties as assigned.  

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 6 years of clinical nursing experience with at least 4 years of leading staff or supervisory/management experience.

Minimum 3 years relevant health plan experience.

Equivalency:  Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.

Preferred:

Experience with Medi-Cal, under-served and culturally diverse populations.

Experience with state Medi-Cal regulations.

Audit/oversight experience.

Skills

Required:
Excellent verbal and written communication skills.

Strong problem solving, planning, and organizational skills.

Ability to maintain confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Required:
Registered Nurse (RN)

Physical Requirements

Additional Information