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The Manager, UM Regulatory & Compliance - CCA is responsible for the coordination, implementation, and oversight of the IEHP’s overall Utilization Management Out-Patient Operations departmental clinical and operational compliance with regulatory requirements and quality assurance initiatives related to utilization management out-patient activities (e.g., Prior Authorization, UM Call Center operations.
$56.85 - $91.64 an hourExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL. Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families.
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Responsibilities include oversight of safe transitions of care for Members and communication with regulatory agencies and impacted departments (e.g., Pharmacy, Claims, Care Management, Utilization Management, etc.
$240,676.8 a yearExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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Responsible for compliance with Good Manufacturing Practices (GMP) in food and/or pharmaceutical to consistently manufacture products according to quality standards, as well as other customer and regulatory quality standards.
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Key Requirements and Technology Experience: One should have Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques and methods of Utilization review/management, discharge planning or case management.
Full-timeExpandApply NowActive JobUpdated 2 days ago - UpvoteDownvoteShare Job
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Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques and methods of Utilization review/management, discharge planning or case management. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities.
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Working knowledge of regulatory requirements and accreditation standards (TJC, Medicare, Medi-Cal, etc. Reviews, analyses and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities.
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Three (3) or more years of any individual or combined experience in quality assurance, utilization management, case management, and/or health care informatics is required. Maintains summarized information for Quality Systems related to modified and new regulatory requirements for medical management from DHCS, DMHC and CMS.
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This role oversees the seamless integration of transitional care into Utilization Management operations, ensuring regulatory compliance, effective project management, and the deployment of new and existing requirements.
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Provides leadership and management of clinical care coordination, utilization management, discharge planning, and outcomes management. Responsible for goal setting, program planning, work flow processes, regulatory compliance, staff productivity, facilitation of work teams, quality of work, outcome evaluation and continuous quality improvement.
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