Manager, UM Clinical - Prior Authorization

Date: Jul 21, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 5380 

 

Position Summary/Position

 

Under the direction of the Director of UM Operations, the Manager, UM Clinical - Prior Authorization is responsible for the day-to-day management of the Prior Auth Team assuring that compliance and adherence to regulatory entities are completed in a timely, fair, consistent manner using nationally recognized criteria in conjunction with UM Subcommittee Criteria and other medical criteria as outlined per policy. This position is also accountable for the development and implementation of specialty programs that address high cost, high risk populations to provide navigation programs for IEHP members who require special, monitoring, handling, coordination and authorization of services and resources to address their chronic disease needs as they progress through various stages of their disease process.  This position interfaces with internal and external customers and Members to facilitate improved care coordination, navigation, and referral authorization services. 

Major Functions (Duties and Responsibilities)

 

1. Oversight of the application of clinical criteria for the Utilization Management Team to ensure adherence, consistent application of criteria, monitoring always ensuring audit readiness. 
2. Manage and train UM Staff that includes but not limited to: Managed care principles. DMHC, DHCS, CMS and NCQA regulations and mandates.   
3. Provide leadership and supervision of day-to-day prior authorization functions to ensure high quality, cost effective services to Members. Assess current workload and assist team to ensure prompt, comprehensive evaluations, and recommendations.
4. Responsible for ensuring that all prior auth activities are performed timely and on an provide status on and hoc basis as needed.  
5. Assist with building programs specific to high cost. Identify high utilizing members to, monitor, coordinate and navigate appropriate care for specific diseases such as organ failure, Pain, Chronic Kidney Disease, etc.
6. Build strong collaboration and rapport with external delegates and internal teams and medical directors.  
7. Build tools and resources to handle new programs to provide state of the art care for IEHP members for specific diseases.
8. Interface with key IEHP managers to resolve issues and establish or refine policies and protocol for ensuring high customer service and health care services delivery. 
9. Assist in the ongoing monitoring of the interface between clinical services, claims processes, contracting and other units impacting UM. 
10. Assist in updating the resource manual for specific data point capture that is relevant to staff processes.
11. Contribute to the development of annual Department Work Plan and evaluation in collaboration with the Directors of UM.
12. Assist in the development of internal and external Policy and Procedure Manuals. 
13. Assist in the design and development of outpatient utilization management reports, such as staff productivity, authorizations approved/denied by line of business, dashboard reports, etc.; assures that the Supervisors of the above programs understand and use the reports effectively to manage the delivery of services.
14. Implement and operationalize programs using LEAN strategies.
15. Foster an environment of professional growth and learning and perform Human Resource functions aligned with IEHP mission and values; assure job descriptions and staff roles/responsibilities are accurate and current; responsible for execution of program goals.
16. Providing open lines of communication with Delegates and providers on issues related to IEHP UM policies and procedures.

Supervisory Responsibilities

Leader: Administers Hires, Terminations, and Performance Reviews

Experience Qualifications

 

Two (2) or more years of experience in leadership with managed Care, program development and or delegation oversight of medical groups and vendors.

Education Qualifications

 

Bachelor’s degree from an accredited institution required.

Professional Licenses

 

Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California BRN required.

 

OR

 

Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required.

Drivers License Required

Yes, must have a valid California Driver's License.

Knowledge Requirement

 

Possess an in-depth knowledge of all aspects of managed care operations with extensive knowledge of HMO and IPA operations with an emphasis on Utilization/ Case Management and program development.

Skills Requirement

 

Strong analytical skills, time management, and problem solving. Adept at Microcomputer applications (Microsoft Word and Excel, Power Point required for use in all aspects of an office environment. Excellent communication, interpersonal and organizational skills.  

Abilities Requirement

 

Self-starter and a team player. Must have a high degree of patience.

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

 

Need to have transportation and light travel required in and outside of Inland Empire. 

 

Starting Salary: $111,550.40  - $142,230.40  

Pay rate will commensurate with experience

 

Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.

 


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles