Manager, ECM Operations & Oversight

Position Summary/Position

The Manager, ECM Operations & Oversight is responsible for coordinating, implementing, and oversight of all ECM Providers and Care Teams operational compliance with regulatory requirements and quality assurance initiatives related to prior authorization and concurrent utilization management activities. This role is responsible for the oversight of all ECM operations that have an impact with regulatory correspondence including delivery and content. This role will assist with the implementation and revision of policies and standards. This role requires collaboration and communication with various departments that share ECM including UM 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 compliance and quality assurance functions within the ECM Department to ensure that regulatory standards are being adhered to as outlined by DHCS, CMS, DMHC and NCQA
2. Maintain a working knowledge of the ECM-UM Operations and medical management systems been utilized to facilitate oversight to ensure criteria is met for authorizations, denials, and disenrollment.
3. Review chart documentation in care management platform, create quality improvement tools, and conduct monthly audits to ensure compliance and adherence to standards and requirements. Collaborate with Medical Director and department leader’s leader to share findings and provide training as required in a timely manner. 
4. Conduct internal unit audits to ensure UM processes for ECM are adhered to.
5. Identify issues and collaborates with ECM providers to improve opportunities.
6. Monitor Corrective Action Plan related to deficiencies of noncompliance. Train ECM Providers and Care Teams on noncompliance findings, use evidence-based research to promote best practices and adhere to new regulations requirements to ensure continuous cost-effective, high-quality care for Members and providers.
7. Ensure that ECM-UM processes are tested and validated when changes are made in IEHP’s Medical     Management System and Care Management platform and obtain approval from all stakeholders impacted.
8. Coach and mentor staff to promote process improvement and to foster team culture.
9. Collaborate and communicate with ECM management on issues and processes that impact UM, ECM, and others to facilitate a consistent work process that promotes improved, high work output and embraces lean concepts.   
10. Manage the implementation of new Population of Focus (POF) and Model of Care (MOC) processes.
11. Accountable for continued refinement and growth of staff development.
12. Explore and implement processes to promote auto adjudication of service requests.

Major Functions (Duties and Responsibilities) Cont

Supervisory Responsibilities

Experience Qualifications

Five (5) or more years of health care experience of which three (3) or more are in supervisory. Experience in utilization management required. History of successful responsibilities and success. Project management required. Team building experience essential. Working experience with State and Federal requirements (DHCS, CMS, DMHC) and quality standards (NCQA). Experience in an HMO or managed care setting required, including Medicare Advantage health plan.

Preferred Experience

Education Qualifications

Bachelor’s degree from an accredited institution required.

Preferred Education

Master’s degree in MPH, MA, MSN, MBA, or related field from an accredited institution preferred.

Professional Certification

Professional Licenses

Drivers License Required

Knowledge Requirement

Thorough Expert knowledge of state and federal requirements and regulations of CMS, DHCS, DMHC, and NCQA. Understanding and sensitivity to a multi-cultural environment and community. Project Management, LEAN, and ECM required.
Knowledgeable in Care Director platform and Care Prominence Medical Management Systems.

Skills Requirement

Excellent writing and communication skills.

Abilities Requirement

Must have a high degree of patience, attention to detail, and time management capabilities. The ability to prioritize competing priorities, and organizational skills.

Commitment to Team Culture

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions

Word processing involving computer keyboard and screens, automobile travel within the Inland Empire. 

Position is eligible for Hybrid work location upon completing the necessary steps and receiving HR approval. All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership.

Work Model Location

Physical Requirements