Under direction from the Director of Utilization Management, manages and provides direction to the Health Services department Managers for all product lines ensuring consistent development, implementation, and maintenance of health services programs and achievement of department goals and objectives, in a fast paced, ambiguous environment. Ensures compliance with established criteria and PHC benefits.
SECONDARY DUTIES AND RESPONSIBILITIES
Education and Experience
Bachelor’s degree in Nursing. Minimum five (5) years of clinical experience; three (3) years of managed care (utilization or case management) experience; minimum one (1) year of management experience in a medical management setting, with effective problem solving in an area where few precedents have been set; or equivalent combination of education and experience.
Special Skills, Licenses and Certifications
Current California Registered Nurse license. Effective telephone and computer skills required. Working knowledge and experience with ICDCM and CPT coding schemes. Thorough knowledge of utilization and case management programs and application of related clinical criteria and protocols. Knowledge of and experience with Federal Medicaid and/or California Medi-Cal programs preferred. Ability to work effectively across departments and functions within the organization. Competency with PCs and medical management software, word processing, spreadsheets, etc. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.
Performance Based Competencies
Demonstrated effective leadership and analytical skills. Effective oral and written communication skills. Excellent interpersonal skills.
Work Environment And Physical Demands
Ability to use a computer keyboard. Ability to prioritize workload and initiate action to acquire needed information from professionals by phone. Ability to function effectively with frequent interruptions and direction from multiple team members. More than 50% of work time is spent in front of a computer monitor. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs.
Additional Preferred Skills: Able to multi-task, be flexable, and self motivated. NCQA knowledge preferred as this position works closely with NCQA teams.
All HealthPlan employees are expected to:
IMPORTANT DISCLAIMER NOTICE
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.