Manager of Utilization Management

Prospect Medical is Southern California’s 3rd largest IPA---and growing!

 Come join our team of dedicated professionals committed to providing quality service and quality care to our 1500+ primary care and 9000 specialist physicians and to our 250,000+ members.





 Prospect is looking for an ideal candidate to fill the

 Manager of Utilization Management position: 

Job Purpose:

Provides effective oversight, direction and leadership  of the utilization management and compliance process to include health plan reporting and audits, denial and delayed decision compliance, staff education and auditing, and high dollar medical record review.  Maintains internal controls for responsible areas.  Ensures that members receive necessary care in the most cost-efficient setting with quality care and quality service.

 Duties:

The following are included but not limited to:

 Ensure compliance is achieved and maintained within guidelines and standards for: stat lines and required TAT, referral production, denial and delayed decision letters, pended referral reports, and review of high dollar, medical necessity cases, retro review and denial of service. Ensure disease management and case management referrals are forwarded to the appropriate individuals. Prepare for and coordinate Health Plan audits to achieve 100% compliance, and resolution for any corrective action plan. Responsible for retro authorization review and over read by Medical Director when indicated. Perform Inter-rater reliability for all clinical UM staff twice per year as required by NCQA/Health Plan requirements. Responsible for semi annual Health Plan coalition reporting. Maintain internal controls and successful oversight for all responsible areas under UM and compliance. Carry out supervisory responsibilities including sourcing and interviewing, planning, assigning and directing work, timely appraisal of performance, training, recognition, discipline, and addressing complaints and resolving issues. Special projects as assigned by Medical Director, or Vice President of Healthcare Services. Supervises and oversees operation of Medi-Cal program by directing all Medi-Cal administrative functions to include:  oversight of case management, utilization management, quality management and submission of reports as required per health plan contract. Oversight of the sub-contracted PSS Department and submission of required reports. Attend various Cal-Optima and/or Health Plan meetings as necessary. Plan, develop and coordinate activities/procedures to ensure compliance with NCQA, DHS, and DMHC. Oversight and develop plan for annual CalOptima audit. 

 

Skills/Qualifications:

RN LicenseMust have 5-7 years experience in Managed Care, Case Management, Utilization Management, Medi-Cal and Compliance.Previous management experience, preferably 3 – 5 years. Experience with Health Plan audits, denial letter, compliance and knowledge of standardized criteria for decision making.Knowledge of Microsoft Word (30 wpm), Excel, PowerPoint and Outlook.Extremely organized, detail oriented, and the ability to multi task in a fast paced environment.

 

While performing this job, the employee is regularly required to sit; use hands to finger, handle, and/or feel; and talk and/or hear.  The employee frequently is required to stand and/or walk.  The employee is occasionally required to climb or balance and stoop, kneel, crouch, and/or crawl.  The employee must regularly lift and/or move up to ten (10) pounds and frequently lift and/or move up to twenty-five (25) pounds.  Specific vision abilities required by this job include close vision.

 

Prospect Medical has a solid past and a dynamic future.  Nearly 20 years old, we have grown and matured---we are now publicly-traded (AMEX:PZZ), IPA and medical management services company.  We contract with all major regional HMO’s including PacifiCare, Blue Cross, Health Net and CIGNA.  We are now serving California’s seniors with a superior Medicare program, and we are pursuing additional growth through a strategy of targeted acquisition.  We succeed through the use of superior technology, proven management procedures, and committed employees. Our success allows us to offer excellent compensation and one of the best benefit packages in the industry.

If you are a qualified, high-achieving professional who wants to make a positive difference in the world of managed care, please submit your resume online.

Quality Service, Quality Care…that’s who we are!



Looking for a great company who cares, then you should call Prospect today!



Please visit our website for more information and a listing of all our open positions
www.prospectmedicalholdings.com