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Manager, UM Regulatory & Compliance - CCA

Company: Inland Empire Health Plan
Location: Rancho Cucamonga
Posted on: June 11, 2024

Job Description:

What you can expect!Find joy in serving others with IEHP! We welcome you to join us in "healing and inspiring the human spirit" and to pivot from a "job" opportunity to an authentic experience!The Manager, UM Regulatory & Compliance - CCA is responsible for the coordination, implementation, and oversight of the IEHP's overall Utilization Management Out-Patient Operations departmental clinical and operational compliance with regulatory requirements and quality assurance initiatives related to utilization management out-patient activities (e.g., Prior Authorization, UM Call Center operations). This position will also oversee delegate clinical and operational compliance with regulatory requirements and quality assurance initiatives related to utilization management out-patient activities. This role is responsible for the oversight/generation of all Utilization Management preservice regulatory correspondence including delivery and content. This role will assist the Director, UM Operations with the implementation and revision of policies and standards. This role requires collaboration and communication with various departments that share Utilization Management functions. This role will inspire and influence the team towards cultural transformation of the department through continuous improvement.Major Functions (Duties and Responsibilities)1. Oversee the compliance, training, and quality assurance functions within the Utilization Management Out-Patient Services unit to ensure Utilization Management policy and protocol are being adhered to as outlined by DMHC and NCQA.2. Maintain working knowledge of the DOFR related to both facility and professional components for all IPA's.3. Ensure all prior authorization activities meet content and delivery requirements.4. Issue and monitor Corrective Action Plans related to deficiencies of noncompliance. Develop action plans in accordance with identified issues.5. Act as in-house expert regarding Utilization Management process. Ensure adherence and consistent application of non-clinical and clinical Utilization Management criteria always ensuring audit readiness.6. Communicate and train Utilization management clinical and non-clinical staff and delegates on best practices and new regulations and requirements to ensure coordinated, continuous, cost-effective quality outpatient health care for Members and Providers.7. Ensure Utilization Management processes are tested and validated when changes are made in the medical management system.8. Ensure all out-patient activities follow regulatory adherence (E.g., UM Call Center activities to COC, OG, OD, Provider redirection requests, Out-patient denials and member notifications are received, processed, and completed within regulatory timeframes).9. Collaborate with the Medical Directors to ensure timely processing of referrals and denials.10. Lead audit related activities (e.g., Monthly review of the referral universe, mailroom compliance for the Utilization Management mailing ensuring adherence to regulatory requirements).11. Collaborate and communicate with management on issues and processes that impact Utilization Management and other organizational entities internally and externally.12. Foster a fair work environment to assure that hiring, on-boarding and continued education is provided to staff to improve engagement, productivity, and quality. Coach and mentor staff to promote process improvement and to foster team culture.13. Accountable for continued refinement and growth of staff development. Develop and implement training programs for staff.14. Assure LEAN principles are utilized and PDSA cycles are performed for all UM department processes to assist in the transformation of becoming a 5 Star Health Plan.15. Explore and implement processes to promote auto adjudication of service requests.16. Design and develop Outpatient Utilization Management reports, such as staff productivity, authorizations approved/denied by line of business, dashboard reports, etc.; assures that the Supervisors of the above programs understand and use the reports effectively to manage the delivery of services.17. Explore, promote, and coordinate implementation of new Utilization Management software and processes. Build tools and resources to handle new programs to provide state of the art care for IEHP Members.18. Maintain internal and external policies and procedures relating to Utilization Management Out-Patient Services unit.19. Provide open lines of communication with Utilization Management staff, IEHP delegates and providers on issues related to IEHP Utilization Management policies and procedures. Build strong collaboration and rapport with external delegates and internal teams and medical directors.20. Forecast and plan for future based on growth of the department.21. Any other duties as required ensuring Health Plan operations are successful.Commitment to Quality: The IEHP Team is committed to incorporate IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.PerksIEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.Competitive salary.Hybrid schedule.CalPERS retirement.State of the art fitness center on-site.Medical Insurance with Dental and Vision.Life, short-term, and long-term disability optionsCareer advancement opportunities and professional development.Wellness programs that promote a healthy work-life balance.Flexible Spending Account - Health Care/ChildcareCalPERS retirement457(b) option with a contribution matchPaid life insurance for employeesPet care insuranceEducation & ExperienceFive (5) or more years of experience in utilization management in a health care delivery setting. Three (3) or more years of supervisory experience with project management and team building experience essential. Working experience with State and Federal requirements (DHCS, CMS, DMHC) and quality standards (NCQA). Supervision can include managing projects and leading the participants of the project to successful implementation. Experience with training/mentoring newer Team Members. Organizing a workgroup to drive the successful implementation of a major program or process. Experience with Commercial Plan Coverage required.Bachelor's degree in related field from an accredited institution required.Candidate with an active, unrestricted, and unencumbered Registered Nurse (RN) issued by the California BRN without a Bachelor's degree will require four (4) years of additional relevant work experience. This experience is in addition to the minimum years listed in the Experience Requirements above.Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required.Yes, must have a valid California Driver's license and valid automobile insurance. Must qualify and maintain driving record to drive company vehicles based on IEHP insurance standards of no more than three (3) points.Understanding and sensitivity to a multi-cultural environment and community.Key QualificationsState and federal requirements and regulations of CMS, DHCS, DMHC, and NCQA.All aspects of managed care operations with extensive knowledge of HMO and IPA operations with an emphasis on Utilization/ Case Management and program development. Commercial managed care coverage.ICD-10 and CPT/HCPC codes.Start your journey towards a thriving future with IEHP and apply TODAY!

Keywords: Inland Empire Health Plan, Rancho Cucamonga , Manager, UM Regulatory & Compliance - CCA, Executive , Rancho Cucamonga, California

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