Case Management Society of America (CMSA) ®
Utilization Management Manager, Medicare Advantage - RN
Case Management Society of America (CMSA) ®, Los Angeles, California, United States, 90079
Description
Take on a high-impact role within a world‑class health organization. Help drive the continued delivery of exceptional patient care. Take your career to the next level. You can do all this and more at UCLA Health.
As a Manager for Medicare Advantage Utilization Management, you’ll provide direct management to a team of UM coordinators and nurses. You’ll work closely with Medicare Advantage leadership to plan, execute, and manage various initiatives related to UM administrative, operational, and strategic objectives. You’ll demonstrate leadership and effective communication by fostering collaborative relationships with peers, co‑workers, and staff. You’ll be responsible for overseeing and coordinating the following major functions:
Pre‑service Authorizations/Denial Letters
Concurrent Review
Continuity of Care
Retro Claims
Retrospective Review
Referral Automation Business Rules/Configuration
Salary Range: $112,900 - $256,900 Annually
Qualifications We’re seeking a self‑motivated, detail‑oriented, service‑driven leader with:
Current unrestricted RN licensure in CA required
Bachelors of Science, Nursing (BSN) degree required
Five or more years of utilization management required
Four or more years of managerial experience required
Four or more years of clinical experience providing direct patient care
Experience in an HMO environment
Thorough knowledge of health care industry, utilization review, utilization management, and concurrent review ACM/CCM preferred
Knowledge of Health Plan, DMHC, CMS, HIPPA and NCQA requirements
Familiarity with CPT‑4, ICD‑10, and HCPCS codes
Proficient computer skills including Internet search capabilities, Microsoft Word, Excel and Managed Care software (i.e. EZ Cap, Diamond, IDX)
Strong critical thinking, problem solving, and analytical skills
Excellent communication, organizational, and prioritizing skills required
Ability to develop, implement, and evaluate methods and systems to improve efficiency
Ability to lead and facilitate cross‑functional workgroups and other meetings
Skill in working with complex organizations to comply with regulatory requirements
Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, health plan requirements and State/Federal regulations
Ability to analyze and organize complex federal and private insurance regulations
Ability to travel/attend off‑site meetings and conferences
ACM - Accredited Case Manager preferred
CCM - Certified Case Manager preferred
Named one of the top hospitals in the nation by U.S. News & World Report, UCLA Health features four award‑winning hospitals and more than 250 community clinics throughout Southern California as well as the David Geffen School of Medicine. If you’re looking to experience greater challenge and fulfillment in your career, you can at UCLA Health.
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As a Manager for Medicare Advantage Utilization Management, you’ll provide direct management to a team of UM coordinators and nurses. You’ll work closely with Medicare Advantage leadership to plan, execute, and manage various initiatives related to UM administrative, operational, and strategic objectives. You’ll demonstrate leadership and effective communication by fostering collaborative relationships with peers, co‑workers, and staff. You’ll be responsible for overseeing and coordinating the following major functions:
Pre‑service Authorizations/Denial Letters
Concurrent Review
Continuity of Care
Retro Claims
Retrospective Review
Referral Automation Business Rules/Configuration
Salary Range: $112,900 - $256,900 Annually
Qualifications We’re seeking a self‑motivated, detail‑oriented, service‑driven leader with:
Current unrestricted RN licensure in CA required
Bachelors of Science, Nursing (BSN) degree required
Five or more years of utilization management required
Four or more years of managerial experience required
Four or more years of clinical experience providing direct patient care
Experience in an HMO environment
Thorough knowledge of health care industry, utilization review, utilization management, and concurrent review ACM/CCM preferred
Knowledge of Health Plan, DMHC, CMS, HIPPA and NCQA requirements
Familiarity with CPT‑4, ICD‑10, and HCPCS codes
Proficient computer skills including Internet search capabilities, Microsoft Word, Excel and Managed Care software (i.e. EZ Cap, Diamond, IDX)
Strong critical thinking, problem solving, and analytical skills
Excellent communication, organizational, and prioritizing skills required
Ability to develop, implement, and evaluate methods and systems to improve efficiency
Ability to lead and facilitate cross‑functional workgroups and other meetings
Skill in working with complex organizations to comply with regulatory requirements
Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, health plan requirements and State/Federal regulations
Ability to analyze and organize complex federal and private insurance regulations
Ability to travel/attend off‑site meetings and conferences
ACM - Accredited Case Manager preferred
CCM - Certified Case Manager preferred
Named one of the top hospitals in the nation by U.S. News & World Report, UCLA Health features four award‑winning hospitals and more than 250 community clinics throughout Southern California as well as the David Geffen School of Medicine. If you’re looking to experience greater challenge and fulfillment in your career, you can at UCLA Health.
#J-18808-Ljbffr