Utilization Management Manager, Medicare Advantage - RN

DescriptionTake on a high-impact role within a world-class health organization. Help drive the continued delivery of exceptional patient care. Take your career to the next level. You can do all this and more at UCLA Health.As a Manager for Medicare Advantage Utilization Management, you'll provide direct management to a team of UM coordinators and nurses. You'll work closely with Medicare Advantage leadership to plan, execute, and manage various initiatives related to UM administrative, operational, and strategic objectives. You'll demonstrate leadership and effective communication by fostering collaborative relationships with peers, co-workers, and staff. You'll be responsible for overseeing and coordinating the following major functions:Pre-service Authorizations/Denial LettersConcurrent Review Continuity of Care Retro ClaimsRetrospective ReviewReferral Automation Business Rules/ConfigurationSalary Range: $112,900 - $256,900 AnnuallyQualificationsWe're seeking a self-motivated, detail-oriented, service-driven leader with:Current unrestricted RN licensure in CA requiredBachelors of Science, Nursing (BSN) degree required Five or more years of utilization management requiredFour or more years of managerial experience requiredFour or more years of clinical experience providing direct patient careexperience in an HMO environmentThorough knowledge of health care industry, utilization review, utilization management, and concurrent review ACM/CCM preferredKnowledge of Health Plan, DMHC, CMS, HIPPA and NCQA requirementsFamiliarity with CPT-4, ICD-10, and HCPCS codesProficient 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 skillsExcellent communication, organizational, and prioritizing skills requiredAbility to develop, implement, and evaluate methods and systems to improve efficiencyAbility to lead and facilitate cross-functional workgroups and other meetingsSkill in working with complex organizations to comply with regulatory requirementsAbility to read, analyze and interpret general business periodicals, professional journals, technical procedures, health plan requirements and State/Federal regulationsAbility to analyze and organize complex federal and private insurance regulationsAbility to travel/attend off-site meetings and conferencesACM - Accredited Case Manager preferredCCM - Certified Case Manager preferredNamed one of the top hospitals in the nation by U.S. News & World Report, UCLA Health features four award-winning hospitals and more than 250 community clinics throughout Southern California as well as the David Geffen School of Medicine. If you're looking to experience greater challenge and fulfillment in your career, you can at UCLA Health.