County of Contra Costa
Utilization Review Manager (Contra Costa Health Plan)
County of Contra Costa, Martinez, California, United States, 94553
Overview
The Contra Costa Health Department is seeking to fill one (1) Utilization Review Manager position in Contra Costa Health Plan, located in Martinez, CA. Contra Costa Health Plan (CCHP) is a mission-driven, county-operated managed care organization delivering high-quality health coverage to more than 250,000 members across Medi-Cal, commercial, and beginning in 2026, Medicare-Medi-Cal (D-SNP) lines of business.
Role We are seeking a strategic, experienced, and collaborative Utilization Review Manager to lead our Utilization Management Department across all lines of business. This is a pivotal leadership opportunity at a critical moment in CCHP’s growth and transformation. With increasing regulatory expectations from the Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), and Centers for Medicare and Medicaid Services (CMS), and the implementation of new care models under CalAIM and the upcoming Medicare and Medi-Cal Dual Special Needs Plan (D-SNP), regulatory compliance is more critical than ever. The Utilization Review Manager will be responsible for leading a team of clinical and administrative staff to ensure timely, compliant, and member-centered utilization management processes.
Responsibilities
Managing and monitoring day-to-day clinical review operations and authorizations
Leading the development and implementation of utilization management policies and workflows
Ensuring turnaround time compliance and accuracy in decision-making and member/provider notifications
Preparing for and responding to audits, including CMS, DMHC, and delegated UM reviews
Collaborating with internal departments and external providers to support coordinated and efficient member care
Developing reports and data tools that drive insights and accountability
Interviewing, hiring, orienting, evaluating, counseling, and recommending discipline of staff
Supervising and training staff
Qualifications
License Required:
Possess and maintain throughout employment a current, valid, and unrestricted license as a Registered Nurse issued by the California Board of Registered Nursing.
Education:
Possession of a bachelor's degree in nursing from an accredited college or university.
Experience:
Three (3) years of full-time, or its equivalent, experience as a Registered Nurse in a managed care organization (i.e., HMO), two (2) years of which must include experience as a Utilization Review Nurse, Discharge Planner, or Case Management Nurse, and one (1) year of which must have been in a supervisory capacity.
Substitution:
Two (2) additional years in a Nurse Supervisor capacity may be substituted for the Bachelor's degree. A Master’s Degree in nursing, hospital or health care administration or a closely related field may be substituted for one (1) year of RN experience. No substitution is allowed for the required one (1) year of supervisory experience.
Application and Selection
Application Filing and Evaluation:
Applicants will be required to complete a supplemental questionnaire at the time of application. Applications will be evaluated to determine which candidates will move forward in the next phase of the recruitment process.
Training & Experience Evaluation:
At the time of filing, candidates will be required to complete a supplemental questionnaire, which will be used for the training and experience evaluation. Candidates who clearly demonstrate that they possess the minimum qualifications will have their training and experience evaluated. The responses to the supplemental questions, at the time of filing, will be evaluated to determine each candidate's relevant education, training, and/or experience as presented on the application and supplemental questionnaire. (Weighted 100%)
Additional Information The Human Resources Department may change the examination steps noted above in accordance with the Personnel Management Regulations and accepted selection practices.
Policy and Compliance
CONVICTION HISTORY:
After you receive a conditional job offer, you will be fingerprinted. The resulting report will be used to determine whether a conflict exists with the duties of the job. Having a conviction history does not automatically preclude employment.
DISASTER SERVICE WORKER:
All Contra Costa County employees are designated Disaster Service Workers and must complete related training as assigned.
EQUAL EMPLOYMENT OPPORTUNITY:
Contra Costa County considers all applicants without regard to protected characteristics.
Applicants are required to attach a copy of their license to their application.
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Role We are seeking a strategic, experienced, and collaborative Utilization Review Manager to lead our Utilization Management Department across all lines of business. This is a pivotal leadership opportunity at a critical moment in CCHP’s growth and transformation. With increasing regulatory expectations from the Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), and Centers for Medicare and Medicaid Services (CMS), and the implementation of new care models under CalAIM and the upcoming Medicare and Medi-Cal Dual Special Needs Plan (D-SNP), regulatory compliance is more critical than ever. The Utilization Review Manager will be responsible for leading a team of clinical and administrative staff to ensure timely, compliant, and member-centered utilization management processes.
Responsibilities
Managing and monitoring day-to-day clinical review operations and authorizations
Leading the development and implementation of utilization management policies and workflows
Ensuring turnaround time compliance and accuracy in decision-making and member/provider notifications
Preparing for and responding to audits, including CMS, DMHC, and delegated UM reviews
Collaborating with internal departments and external providers to support coordinated and efficient member care
Developing reports and data tools that drive insights and accountability
Interviewing, hiring, orienting, evaluating, counseling, and recommending discipline of staff
Supervising and training staff
Qualifications
License Required:
Possess and maintain throughout employment a current, valid, and unrestricted license as a Registered Nurse issued by the California Board of Registered Nursing.
Education:
Possession of a bachelor's degree in nursing from an accredited college or university.
Experience:
Three (3) years of full-time, or its equivalent, experience as a Registered Nurse in a managed care organization (i.e., HMO), two (2) years of which must include experience as a Utilization Review Nurse, Discharge Planner, or Case Management Nurse, and one (1) year of which must have been in a supervisory capacity.
Substitution:
Two (2) additional years in a Nurse Supervisor capacity may be substituted for the Bachelor's degree. A Master’s Degree in nursing, hospital or health care administration or a closely related field may be substituted for one (1) year of RN experience. No substitution is allowed for the required one (1) year of supervisory experience.
Application and Selection
Application Filing and Evaluation:
Applicants will be required to complete a supplemental questionnaire at the time of application. Applications will be evaluated to determine which candidates will move forward in the next phase of the recruitment process.
Training & Experience Evaluation:
At the time of filing, candidates will be required to complete a supplemental questionnaire, which will be used for the training and experience evaluation. Candidates who clearly demonstrate that they possess the minimum qualifications will have their training and experience evaluated. The responses to the supplemental questions, at the time of filing, will be evaluated to determine each candidate's relevant education, training, and/or experience as presented on the application and supplemental questionnaire. (Weighted 100%)
Additional Information The Human Resources Department may change the examination steps noted above in accordance with the Personnel Management Regulations and accepted selection practices.
Policy and Compliance
CONVICTION HISTORY:
After you receive a conditional job offer, you will be fingerprinted. The resulting report will be used to determine whether a conflict exists with the duties of the job. Having a conviction history does not automatically preclude employment.
DISASTER SERVICE WORKER:
All Contra Costa County employees are designated Disaster Service Workers and must complete related training as assigned.
EQUAL EMPLOYMENT OPPORTUNITY:
Contra Costa County considers all applicants without regard to protected characteristics.
Applicants are required to attach a copy of their license to their application.
#J-18808-Ljbffr