Manager, UM Operations Strategy & Implementation - R12793

Job SummaryThe Manager, Utilization Management (UM) Strategy & Implementation leads a dedicated team that supports the UM program through multiple functions with a focus on all regulatory and compliance functions. This encompasses, but is not limited to, prior authorization analysis and filings, new business implementation, policy development, internal risk analysis, and audit and review preparation for the UM department. This role also manages cross-functional projects as needed to implement standardized/compliant processes across multiple lines of business and markets.Essential FunctionsEstablish a baseline of compliance, regulatory and accreditation risk, identify areas of potential exposure, develop and align strategies for the department’s area of focus with CareSource goals and objectives and execute program ensuring consistencyProficient in current federal/state laws and regulations, industry standards and best practices around compliance, regulatory and accreditation requirementsOversee and manage UM Operations oversight functions such as Corrective Action Plan (CAP) management, ongoing monitoring, and multiple audit activitiesBuild and leverage effective cross-functional business relationships and influence action across multiple internal and external partners to support a culture of complianceResponsible for development and maintenance of documentation related to policy, workflow and process when applicableIdentify process gaps and drive improvements towards UM compliance in all areasOversee and manage process changes across all teams in the department ensuring regulatory, accreditation and compliance business goals are metMaintain an in-depth knowledge of the company’s business, regulatory, compliance and accreditation environments and requirementsDevelop strategy and high-level implementation plans for the delivery of new business implementation, delegation implementation, product filings, regulatory, compliance and accreditation requirementsResponsible for hiring, training, coaching, and developing direct reports including conducting performance reviews and disciplinary actions, as necessarySupport all accreditation initiatives, including licensure applications, NCQA, and URACRepresent UM and clinical on market conduct exams or regulatory inquiriesMonitor and analyze key compliance measuresCollaborate with data and analytics, PH and BH clinical teams, compliance and regulatory to oversee and ensure regulatory reporting is timely and accurateOversee and assist in the creation of the UM and clinical responses for the NQTL regulatory findingsServe as liaison between Clinical Operations, Regulatory, and Compliance Senior leadershipAssure all departmental P&P’s and tools are reviewed at an appropriate cadence and contain required regulatory and accreditation related elementsReport on status of departmental audit readiness and escalate to senior leadership if appropriateCollaborate with data analytics and research team on measurements and insight to ensure all key predictive measures are consistently reported and communicatedPerform any other job related instructions, as requestedEducation And ExperienceBachelor’s Degree in nursing or related field is requiredMaster’s Degree in Business or health care field preferredMinimum of five (5) years clinical or related healthcare industry experience is requiredPrior leadership experience is requiredManaged Care experience is requiredExperience with analysis, data and reporting is requiredAccreditation, auditing, and process improvement experience is preferredDemonstrated change management and continuous improvement leadership skills are strongly desiredCompetencies, Knowledge And SkillsProficient use of Microsoft Office Suite, to include Word, Excel, PowerPoint, Outlook, and Visio with a strong willingness to learnFluent in NCQA and/or CMS, accreditation and audit standards with knowledge of regulatory reporting, compliance requirements, and auditing proceduresDecision making/problem solving and critical thinking skillsPlanning, problem identification and resolution skillsStrong oral, written and interpersonal communication skillsEnergetic, enthusiastic and politically astuteResponsive to a changing environment/change resiliencyProficiency with quality improvement, performance improvement and operationsAbility to develop, prioritize and accomplish multiple competing goalsStrong collaboration skills with ability to work with multi-disciplinary departmentsAbility to work independently and within a teamStrong attention to detail and time management skillsCustomer service oriented with de-escalation skillsAbility to gather/analyze data and create meaningful action itemsAbility to review and implement evidence-based trendsLicensure And CertificationCurrent, unrestricted Registered Nurse (RN) licensure is preferredSix Sigma or project management certifications are preferredWorking ConditionsGeneral office environment; may be required to sit or stand for extended periods of timeCompensation Range$83,000.00 - $132,800.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.Compensation TypeSalaryCompetencies Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the BusinessThis job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.