Manager Medical Management - Health Services

Manager Medical Management - Health Services

Manager Medical Management - Health Services

Location: San Diego County

Hours: 8-hour day shift; weekends as needed

Experience: 2-5 years

Degree: Bachelor

Required Skills and Qualifications:

• At least one of the following is required:
• Current unencumbered California RN license
• Graduate of NLN accredited school of nursing
• Bachelors of Science in Nursing and Master's degree in a healthcare, business or leadership related discipline
• Minimum of three (3) years of Utilization/Quality/Case Management experience in a Managed Care setting
• Two (2) years managerial experience and knowledge of current standards of practice and available health resources in the community
• Participation in a Utilization Management, Case Management or Quality Improvement organization
• Excellent verbal and written communication and presentation skills
• Strong ability to work well with staff for various educational and professional skills backgrounds to achieve common goals and promote collaboration
• Demonstrated leadership and mentoring skills
• Thorough computer knowledge, including on-line data base and personal computer skills
• Knowledge of a wide variety of local and national resources for use in Utilization Management process
• Strong organizational skills with ability to work well under pressure with conflicting priorities
• Ability to analyze and interpret data and prepare concise, accurate reports
• Ability to initiate studies, gather statistical data and trend outcomes
• Strong analytical and problem-solving skills
• Ability to develop and implement projects

Summary:

Under the direction of the Director of Medical/Network Management and in collaboration with the Chief Medical Officer (CMO), Health Services Directors and Managers, this Manager provides leadership and management and is accountable for promoting effective Utilization and Case Management programs (care management).

This position is responsible for managing projects, solving problems and researching data to facilitate business activities for the implementation and maintenance of an effective Utilization Management (UM) and Case Management program. These programs encompass a "Patient-Centered" Care Management approach that includes prior authorization, complex case management, and quality management and compliance components.

The Medical Management Manager provides direct management of the Utilization Management/Case Management team, models effective leadership and mentoring skills for the Case Manager Nurses and LVN Coordinator and promotes staff development. This role provides mentoring skills using the concepts and tools supporting the "Sharp Experience" and maintains regulatory and legislative compliance for the Department.

Responsibilities also include developing and implementing operational policies and procedures that have a direct impact on the UM/CM programs in accordance with NCQA standards, legislative, and contracted health plan requirements.

The manager must have experience working with products lines of business that include; commercial, PPO, POS, state and federal plans (MA, Exchanges)

Under the director of the Director of Medical/Network Management, develops and implements policies and procedures for care management that includes prior authorizations, retrospective reviews, and case management to promote compliance and overall effectiveness of departmental operations. Uses data to measure and promote effective departmental operations.

Essential Physical Requirements include:

• Ability to spend approximately 4-6 hours per day sitting at desk, entering data on computer terminal and talking on telephone.
• Ability to walk approximately 1 -2 hours per day walking between Plan departments.
• Ability to hear and speak clearly by telephone.
• Ability to meet frequent deadlines and tight schedules.
• Ability to lift 5 - 20 pounds, primarily paper reports and filing
• Ability to travel between Sharp Health Plan facilities, physician offices, hospitals, Skilled Nursing Facilities and community resources.
• Must provide own transportation
• Additional physical requirements of position may be discussed during interview.

Sharp HealthCare is proud to be an Equal Opportunity/Affirmative Action Employer (M/F/Disability/Vet).