Manager Medical Management - Health Services

Manager Medical Management - Health Services 

San Diego

Healthcare / Health Services - Managed Care

Exp 2-5 years

Degree Bach

Job Description

 Manager Medical Management - Health Services 

Qualifications

Location

This position is located in, San Diego County

Hours

8-hour day shift; weekends as needed

Required Skills and Qualifications

• At least one of the following is required: 

o Current unencumbered California RN license

o Graduate of NLN accredited school of nursing

o Bachelors of Science in Nursing andMaster’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

Description

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.

This Health Plan is San Diego’s only locally based commercial health plan. With a personal approach and a superior network of medical groups and physicians, this Health Plan advocates for its members by providing unparalleled quality and access to health care services. It operates as a not-for-profit health plan, committed to delivering the best health care for the best value.

As one of the top-rated health plans in California (as measured by the CAHPS satisfaction survey), the Health Plan serves a growing number of companies, large and small, in San Diego and southern Riverside counties.

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).

SKILLS AND CERTIFICATIONS

Does the candidate have a minimum of 3 years Utilization, Quality or Case Management experience? yes 

Does candidate have experience in Managed Care? yes 

Does candidate participate in a UM, CM or Quality Improvement organization? yes 

Does the candidate have 2 years of managerial experience? 

IDEAL CANDIDATE

The ideal candidate can think outside of the box and is a creative, self-starter with a strong capacity to manage people. This manager will have the ability to develop talent and hold staff accountable for results. The ideal candidate will have Health Plan knowledge and the ability to work with the strict guidelines and regulations of a health plan.

IDEAL CANDIDATE SHOULD HAVE WORKED FOR THE FOLLOWING COMPANY(IES): 

Other health plans with extensive managed care experience.