Utilization Management Manager, Medicare Advantage – RN

Qualifications

• Current unrestricted RN licensure in CA required
• Bachelors of Science, Nursing (BSN) degree required
• Five or more years of utilization management required
• Four or more years of managerial experience required
• Four or more years of clinical experience providing direct patient care
• Experience in an HMO environment
• Thorough knowledge of health care industry, utilization review, utilization management, and concurrent review
• ACM/CCM preferred
• Knowledge of Health Plan, DMHC, CMS, HIPPA and NCQA requirements
• Familiarity with CPT-4, ICD-10, and HCPCS codes
• Proficient computer skills including Internet search capabilities, Microsoft Word, Excel and Managed Care software (i.e. EZ Cap, Diamond, IDX)
• Strong critical thinking, problem solving, and analytical skills
• Excellent communication, organizational, and prioritizing skills required
• Ability to develop, implement, and evaluate methods and systems to improve efficiency
• Ability to lead and facilitate cross-functional workgroups and other meetings
• Skill in working with complex organizations to comply with regulatory requirements
• Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, health plan requirements and State/Federal regulations
• Ability to analyze and organize complex federal and private insurance regulations
• Ability to travel/attend off-site meetings and conferences
• ACM - Accredited Case Manager preferred
• CCM - Certified Case Manager preferred

Pay

Salary Range: $116,300 - $264,600 Annually

Benefits

Details about benefits are not specified in the provided job posting.