WHY CALOPTIMA? CalOptima is the single largest health plan in Orange County, serving 880,000 members, or one in four residents. Our motto — "Better. Together.” — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community’s health. If you’re looking for an opportunity to work for an organization dedicated to improving local health care and serving the needs of the most vulnerable, we encourage you to join CalOptima.

JOB SUMMARY

The Director III (Utilization Management) is responsible for the oversight, planning, organization, implementation and evaluation of all activities and personnel engaged in Utilization Management (UM) departmental operations. The incumbent provides leadership and direction to the Utilization Management department to ensure compliance with all local, state and federal regulations, accreditation standards are current and all policies and procedures meet current requirements. The incumbent will have oversight of CalOptima’s Utilization Management program for CalOptima Community Network, CalOptima Direct and the delegated health networks. The Director III is expected to serve as a liaison for various internal and external committees, workgroups, and operational meetings. 

POSITION RESPONSIBILITIES

Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.

Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department

Directs all aspects of clinical and administrative utilization management staff activities.

Oversees CalOptima’s utilization program, to include:

• Developing and maintaining effective authorization review processes and evaluates and recommends improvements where indicated.

• Ensures department policies, procedures and workflows support staff in daily activities and meet regulatory, contractual and accreditation standards. Assists the Medical Directors, UM workgroup, and subject to approval by the UM committee, in the development, evaluation and application of all utilization criteria used for clinical decision making.

• Collaborates with the UM Medical Director and UM workgroup, and subject to approval by the UM committee, maintains the utilization management program description, prepare the yearly utilization management program evaluation and quarterly updates to the work plan.

• Develops and implements business plans to evaluate existing programs or to be used as a basis to determine if new programs are to be implemented.

Leads the staff responsible for Utilization Management workgroups and the Utilization Management committee.

Coordinates utilization activities with Long Term Services and Support, Case Management, and Population Health Management to improve health outcomes, promote appropriate use of resources and align with organizational and/or departmental goals and objectives.

Monitors and tracks services provided from the health plan service area and/or out of network.

Tracks, analyzes and develops strategies to address outlier performance of utilization metrics and reports on administrative quality indicators pertaining to Utilization Management.

Maintains inter-agency relationships (CCS, County Mental Health, etc.).

Hires, trains, and coaches managerial and supervisory staff. This includes fostering of staff development, ownership, accountability, educational opportunities, team building, and career development.

Develops and directs departmental structure, lines of accountability, job descriptions, interview and hire new staff members, orientation, training programs for all new and existing staff and annual staff evaluation and satisfaction process.

Collaborates with all departments within Medical Affairs and the health plan on the development of special projects/programs as required.

Directs departmental annual budgetary process, to include preparation and approval of operating and capital budgets per policy. Monitor performance and initiate corrective action as necessary to prevent budget variance.

Responsible for on-call activities after hours to ensure coverage on weekends and or holidays and extended timeframes when regular staff are not on duty or available.

Maintains current knowledge of regulatory requirements pertinent to Utilization Management such as Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS), Managed Risk Medical Insurance Board (MRMIB), Department of Managed Health Care (DMHC).

Responds to providers or internal staff who have concerns within departmental standards.

Completes other projects and duties as assigned.

POSSESSES THE ABILITY TO:

• Communicate clearly and concisely, both orally and in writing.
• Proactively present outcomes, barriers remediation and strategy to Executive level leadership.
• Work in an extremely fast-paced environment with multiple competing priorities and matrix reporting relationships.
• Make decisions in a timely manner and clearly communicate to all organizational levels at both a vertical and horizontal manner.
• Present statistical and technical UM data in a clear and understandable manner utilizing appropriate visual aids.
• Effectively supervise and coordinate the work of workgroups engaged in quality improvement activities.
• Communicate findings of utilization reports to providers and internal or external stakeholders.
• Have strong clinical skills.
• Present data and information to a wide range of groups using a variety of delivery methods.
• Establish and maintain effective working relationships with CalOptima leadership and staff.
• Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

EXPERIENCE & EDUCATION:

• Bachelor’s degree required.
• Current, unrestricted Registered Nurse (RN) License to practice in the State of California required.
• 7 years of utilization management experience in a managed care environment required; preferably with Medicare and Medicaid populations.
• 5 years of experience in a supervisory role required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

PREFERRED QUALIFICATIONS:

• Master’s degree preferred.

KNOWLEDGE OF:

• California Medi-Cal and Medicare benefits, regulations and standards.
• Hierarchical clinical criteria, MCG and custom Managed Care Medical Policy
• National Committee for Quality Assurance (NCQA) and CMS standards, Quality Improvement studies, Healthcare Effectiveness Data and Information Set (HEDIS) reporting.
• Data collection and analysis, and management practices as related to quality of medical care.

DEPARTMENT(S):  Utilization Management REPORTS TO:  Executive Director, Clinical Operations FLSA STATUS:  Exempt Salary Garde: S - $74.04 - $122.69 ($154,000 - $255,200)

CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

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Required Skills Required Experience