Utilization Management Strategy Director RN

Profile

We are looking for our next Utilization Management Director (RN) to strategically lead our Utilization Management Department.

This position is available in any of our offices: Merced, Salinas or Scotts Valley. In order to be successful in the position, it requires a local presence and connection to a local office.

PURPOSEFUL WORK

Central California Alliance for Health works in partnership with our contracted providers to promote prevention, early detection and effective treatment, and improve access to quality health care for those we serve. This results in the delivery of innovative community-based health care services, better medical outcomes and cost savings.

We are 500-ish employees who are all working towards our vision of Healthy People, Healthy Communities by living out our values of Equity, Integrity, Improvement and Collaboration in the pursuit of our mission of accessible, quality health care guided by local innovation. Learn more about our history, members, and partnerships here.

WHAT YOU'LL BE RESPONSIBLE FOR

Reporting to the Chief Medical Officer, you will strategically lead the Utilization Management department. The Utilization Management Director (RN) will:

Lead and shape the Utilization Management (UM) strategy for the Alliance while providing management oversight in implementing, directing and monitoring the Utilization Management Department functions, including prior authorizations, concurrent review, medical claims review, appeals and grievances

Direct the Utilization Management Department, act as a subject matter expert, and provide executive level advice and guidance on the Department’s functions and overall business operations

Direct, manage and supervise Utilization Management Department staff

WHAT YOU'LL NEED TO BE SUCCESSFUL

To read the full position description, and list of requirements click here

Knowledge of:

The principles and practices of utilization management

The principles and practices of clinical nursing

Research, analysis and reporting methods

Promoting and applying change management principles

NCQA accreditation standards

Title 22, Knox Keene, Medicaid, Medicare, entitlement programs, and related regulations

Ability to:

Direct, manage, supervise, mentor, train and evaluate the work of staff

Provide leadership, facilitate meetings, and partner with and guide managers and employees in the resolution of issues

Develop, plan, organize and direct programs and activities that are complex in nature and regional in scope

Identify, evaluate, and implement innovations and solutions to optimize, enhance and expand UM programs and activities

Ability to demonstrate strong analytical skills, accurately collect, manage and analyze data, identify issues, offer recommendations and potential consequences, and mitigate risk

Education and Experience:

Current unrestricted license as a Registered Nurse issued by the state of California

Bachelor’s degree in Nursing and a minimum of ten years of utilization management experience which included a minimum of five years of experience in a managed care environment and three years of staff management experience

(a Master’s degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying

OTHER DETAILS

While this position is connected to one of our Alliance offices, we are in hybrid telecommute work environment right now and we anticipate that the interview process will take place remotely.

Our Alliance office locations have officially re-opened as of May 2, 2022 and while some employees may work in full-time telecommute schedules, attendance at quarterly company-wide events or department meetings will be expected.

Based on the nature of work, this position may require onsite presence, which is dependent on business need. Details about this can be reviewed during the interview process.

COVID-19 Vaccine Requirement:

This position requires staff to be fully vaccinated and boosted upon their start date as a condition of employment. Proof of vaccination must be submitted at time of hire. Fully vaccinated and boosted is defined as receipt of the second dose in a 2-dose series (Pfizer & Moderna vaccines) OR receipt of a single-dose vaccine (Johnson & Johnson); AND receipt of the booster (if eligible); AND a 2-week period having passed since the administration of the last vaccine dose.

Additionally, all positions at the Alliance are required to meet these minimum qualifications.

OUR BENEFITS

Medical, Dental and Vision Plans

Ample Paid Time Off

11 Paid Holidays per year

401(a) Retirement Plan

457 Deferred Compensation Plan

Robust Health and Wellness Program

EV Charging Stations

And many more

ABOUT US

We are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us.

Join us at Central California Alliance for Health (the Alliance), where you will be part of a culture that is respectful, diverse, professional and fun, and where you are empowered to do your best work. As a regional non-profit health plan, we serve members in Merced, Monterey and Santa Cruz counties. To learn more about us, take a look at our Fact Sheet

At this time the Alliance does not provide any type of sponsorship. Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship.

Company info

Central California Alliance for Health
Website : http://www.ccah-alliance.org/