Independent Medical Review Analyst

About the Role

The DMHC Help Center educates members about their health care rights and resolves complaints against health plans to ensure a stable and accessible health care delivery system. Under the direction of the Supervisor I, the Analyst II is assigned the more complex program-related responsibilities that require effective interpretation and implementation of the Knox-Keene Health Care Service Plan Act of 1975 (KKA), Title 28 of the California Code of Regulations (CCR), member contracts (e.g., Evidence of Coverage), and program policies and procedures.

The incumbent is responsible for evaluating, monitoring, and reconciling Independent Medical Review (IMR) requests from consumers or forwarded by the Governor, Legislature, California Health & Human Services Agency, DMHC Director, or any of the DMHC’s Executive offices, related to medical necessity and experimental or investigational health plan denials and other health program activities. The incumbent will perform technical, consultative, and analytical work within the IMR Branch and serve as a subject matter expert, including training and auditing activities.

Responsibilities

• Interpret and implement the Knox-Keene Health Care Service Plan Act of 1975 (KKA) and Title 28 of the California Code of Regulations (CCR).
• Evaluate, monitor, and reconcile Independent Medical Review (IMR) requests related to medical necessity and experimental or investigational health plan denials.
• Perform technical, consultative, and analytical work within the IMR Branch.
• Act as a subject matter expert, including conducting training and auditing activities.
• Resolve complex issues independently within short timeframes.
• Provide accurate, clear, and timely advice and direction.
• Cultivate collaborative and cohesive working relationships with team members and external stakeholders.

Requirements

The position requires a Background Investigation, including fingerprinting and an inquiry to the California Department of Justice to disclose criminal records. All applicants not currently employed by the DMHC will be subject to this pre-employment background investigation.

Qualifications

Minimum qualifications are outlined in the Class Specification for Analyst II. Possession of these qualifications will be verified prior to interview and/or appointment.

If using education to meet the minimum qualifications, you must submit a copy of your high school transcripts or college/university transcript(s). Unofficial transcripts may be accepted during the application process; however, submission of official transcripts may be required prior to appointment.

Desirable Qualifications

• Knowledge of principles, practices, and trends in health care insurance.
• Ability to work in a fast-paced and customer service-oriented program environment and organize/prioritize workload to meet demands.
• Ability to work well under pressure and meet deadlines.
• Ability to perform multiple tasks with accuracy, precision, and neatness.
• Ability to thrive and work within a team environment.
• Excellent oral and written communication skills.
• Demonstrated ability to act independently with open-mindedness, flexibility, and tact.
• Proficiency in the use of personal computers and standard office software (e.g., Outlook, Word, Excel, Access, PowerPoint).

Working Conditions

• Work locations: Downtown Sacramento or Rancho Cordova, both near light-rail with various amenities.
• Climate-controlled cubicle and/or office environment with artificial lighting.
• Eligible for hybrid telework, subject to operational needs and State/DMHC Telework Policies. All teleworking employees must be California residents and maintain California residency.

Pay

$6,031.00 - $7,547.00 per month. New to State candidates will be hired into the minimum salary of the classification or minimum of alternate range when applicable.

Effective July 1, 2025, the Personal Leave Program 2025 (PLP 2025) directs a temporary reduction in pay in exchange for PLP 2025 leave credits. The salary range(s) in this job advertisement do not include this temporary salary reduction.

Benefits

Benefit information can be found on the CalHR website and the CalPERS website.

Department Information

The mission of the Department of Managed Health Care (DMHC) is to ensure health plan members have access to equitable, high-quality, timely, and affordable health care within a stable health care delivery system. The DMHC protects the health care rights of 30.2 million Californians by regulating health care service plans, assisting consumers through a Help Center, and preserving the financial stability of the managed health care system.

DMHC values diversity and is committed to fostering an inclusive environment where employees from various backgrounds, cultures, and personal experiences can thrive. The department offers a Someone Like Me program to connect prospective employees with current staff for insights into DMHC culture.