Director of Utilization Management

About Us: Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and Cal MediConnect (Medicare-Medicaid Plan) health insurance plans. About the role: The Director of Utilization Management (UM) is responsible for the clinical and operational management of the Utilization Management Department activities including utilization management, concurrent review, prior authorization, care coordination, discharge planning, retrospective review, and claims support, including staff management to ensure that all administrative utilization management (UM) processes are performed in accordance with applicable state and federal regulatory requirements, SCFHP policies and procedures and business requirements. Day to Day: • Manage and perform utilization management activates to ensure regulations, compliance, criteria, standards, and metrics as established by the Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), and Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and Healthcare Effectiveness Data and Information set (HEDIS) for Medi-Cal and Medicare lines of business. • Responsible for the development, design, implementation, and evaluation of the strategic plan for the UM department including the UM program, work plan, evaluation, and oversight of delegated UM functions. • Maintain accountability for utilization management functions to achieve business and clinical outcomes, meeting contract requirements, and supporting cross departmental initiatives with providers and members. • Manage effectiveness of UM coordinators and nurse’s review, coordination, and processing of prior authorization, concurrent review, discharge planning, and transitions of care activities including appeals, claims, provider disputes in accordance with established policy and standardized guidelines. • Monitor and evaluation of under-/over utilization medical services and durable medical equipment for health outcomes analysis including but not limited to identifying gaps in care, cost effectiveness, vendor administration, and quality improvement opportunities through claims, encounter data, and prior authorization data. • Produce and submit regular reports and data analytics as required for, but not limited to, all medical services, compliance dashboard, regulatory requirements, productivity, clinical operations, benefit changes, implementation, and service quality monitoring. • Direct and participates in various meetings including the Utilization Management Committee, UM delegation oversight meetings, and additional interface with providers, delegates, vendors, hospitals, skilled nursing facilities, and community partners. • Assist Health Services Leadership and Medical Directors with activities to meet departmental and organization objectives and implementing action plans to address issues and improve key performance indicators and selected utilization/cost and quality outcomes. • Responsible for overseeing and maintaining UM contracts and Letter of Agreements (LOA). • Develop, coordinate and approve all departmental budget for the UM department. Assist with education of managers on the budget process and ensure appropriate monitoring of these areas is actionable. • Responsible for staffing ratios and projecting changes in staffing with new programs and member ratios. • Assist with system-wide initiatives as it relates to utilization of medical services and coordination of medical care including UM software/application implementations. About You: • Carries out supervisory/management responsibilities in accordance with the organization’s policies, procedures, applicable regulations, and laws. • Current unrestricted California Registered Nurse (RN) license or qualified health care professional. • Bachelor’s Degree from an accredited four-year institution. • Master’s Degree in Nursing or related field is desired. • Minimum five years of experience in Managed Care, Utilization Management, Quality Improvement, or equivalent. • Minimum five years of experience in a supervisory capacity in a managed care setting. • Comprehensive understanding of applicable standards and regulations pertaining to utilization management programs for DHCS, DHMC, NCQA, CMS and NCQA. • Knowledge of MCG guidelines, InterQual criteria, Medi-Cal Provider Manual, or CMS Guidelines. • Current working knowledge of Medicare and Medi-Cal rules and regulations. Please review the full job description on our Career’s page: https://phf.tbe.taleo.net/phf04/ats/careers/v2/viewRequisition?org=SANTCLAR2&cws=38&rid=3087 Job Type: Full-time Pay: $171,721.00 - $274,753.00 per year Benefits: • Dental insurance • Employee assistance program • Flexible spending account • Health insurance • Life insurance • Paid time off • Retirement plan • Tuition reimbursement • Vision insurance Application Question(s): • Do you have a Comprehensive understanding of applicable standards and regulations pertaining to utilization management programs for DHCS, DHMC, NCQA, CMS and NCQA? • Do you have Knowledge of medical cording practices and Medicare and Medi-Cal rules and regulations? Education: • Bachelor's (Required) Experience: • supervisory capacity in a managed care setting.: 5 years (Required) • Managed Care, UM, QI, or equivalent: 5 years (Required) License/Certification: • California (RN) license or qualified health care prof. (Required) Ability to Commute: • San Jose, CA 95119 (Required) Work Location: In person