Manager, Utilization Management

FLSA Status: Exempt
Department: Health Services
Reports To: Director of Medical Management

The Manager of Utilization Management (UM) is responsible for the direct oversight of internal and external delegated UM functions including the development and implementation of policies, procedures and program development and related quality monitoring. In addition, the Manager of UM is responsible for supervising the Supervisor of UM to ensure that all administrative UM processes are performed in accordance with all applicable state and federal regulatory requirements, SCFHP policies and procedures and business requirements.

• Develop, implement and manage all UM processes for continuous and sustained compliance with all applicable state, federal and NCQA regulatory requirements, SCFHP policies and procedures and general business requirements for all lines of business.
• Develop and implement continuous analysis and quality monitoring of all policies and procedures to evaluate UM staff performance and ensure regulatory compliance, including the development and implementation of effective, measurable corrective action plans to meet targeted strategic outcomes.
• Ensure the integration of UM operations into other internal and external teams/departments including Quality, Long Term Services and Support (LTSS) and Behavioral Health (BH).
• Establish and maintain effective interpersonal relationships with all SCFHP staff, members and/or their authorized representatives, providers and other program or agency representatives.
• Ensure UM Committee preparedness.
• Attend off-site meetings.
• Perform other related duties as required or assigned.

• Recruiting, interviewing, and hiring.
• Developing a high performing department culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives.
• Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance.
• Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees’ needs, ensuring they have the necessary resources to do their work.
• Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews.

• Unrestricted professional RN licensure in the state of California. (R)
• Minimum two years of experience in a supervisory capacity in a managed care setting. (R)
• Understanding and/or experience with Utilization Management. (R)
• Must be knowledgeable of DHCS, CMS, DMHC regulations and NCQA regulatory Population Health standards. (R)
• Ability to consistently meet accuracy and timeline requirements to maintain regulatory requirements.
• Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs. (R)
• Ability to use a keyboard with moderate speed and high level of accuracy. (R)
• Excellent written, verbal, and interpersonal communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing. (R)
• Ability to comply with all SCFHP policies and procedures. (R)
• Ability to think and work under pressure and effectively prioritize and complete tasks within established time frames. (R)
• Ability to assume responsibility and exercise sound judgment when making decisions within the scope of this position. (R)
• Maintenance of a valid California Driver's License and acceptable driving record in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R)