Search Page | Back to Results

Utilization Management Manager, Valley Health Plan

SALARY: $165,561.77 - $212,164.16 Annually

THE POSITION

Under general direction, plans, develops, implements, coordinates, monitors, and evaluates the Utilization Management Department for the Valley Health Plan (VHP) as well as the Authorization Center in Ambulatory & Community Health Services at Valley Medical Center.

Valley Health Plan (VHP) is a non-profit health maintenance organization, that provides Individual, Family, Employer Group, and Covered California plans. VHP is Knox-Keene licensed and is AAAHC accredited.

This is a high-visibility position within VHP that will set the strategy and direction for VHP's Utilization and Care Management Departments. Under direction of the Valley Health Plan Chief Medical Officer, this position oversees all aspects of utilization management for VHP. Strong communication skills are essential since the incumbent will collaborate with other Directors and Executive Management, as well as attend executive management meetings and board meetings on behalf of the Chief Medical Officer.

Primary functions may include, but are not limited to, evaluating current processes and systems; developing, implementing and managing effective and efficient processes/policies; as well as collaborating with other Directors, physicians and medical professionals to support the functional infrastructure. This position will have a vast knowledge of the managed sub-function and overall departmental function.

TYPICAL TASKS


•Develops utilization management guidelines, protocols, policies and procedures for VHP Utilization Department and a diverse network of service providers;
•Reviews and approves referral requests for medical and other specialty services, diagnostic services, and other ancillary services using established medical criteria (per protocol);
•Develops and implements procedures for determining medical necessity, physician review, and a grievance procedure for both members and providers;
•Ensures supervision of staff, oversees utilization management functions, and provides staff with ongoing training to ensure that knowledge of utilization management is up-to-date and that services are provided in an appropriate, culturally sensitive manner;
•Provides quarterly and other reports related to utilization and quality management activities including statistics on claims, service use, and other aspects of the VHP program;
•Collaborates with VHP management and service providers to develop monitoring methods and forms to facilitate timely, appropriate, cost effective service to patients, appraisal of service provider performance, and tracking of data necessary for chronic disease management, complex case management and utilization review;
•Work with the Medical Director - VHP to develop a Utilization Management Work Plan that is diagnosis/disease focused and appropriate to the population being served;
• Provides UM oversight of Valley Health Plan Commercial members; delegated members and the uninsured/underinsured patients who receive services within the County; Coordinates case management and utilization review systems and protocols
•Develops strategic utilization management plans acceptable to providers, provider network and the health community and in compliance with laws and regulations (e.g. HEDIS, Department of Managed Health Care Services (DMHC);
•Maintains competence and knowledge of current trends in care standards and UM, regulatory and accreditation topics;
•Selects, trains, supervises, and evaluates the work of UM staff;
•May be assigned as a Disaster Service Worker, as required;
•Performs related duties as required;



EMPLOYMENT STANDARDS



Possession of a license as a Registered Nurse issued by the California Board of Registered Nursing and the abilities and current knowledge to perform the typical tasks of this position in a health maintenance organization.


Training and Experience Note: The required knowledge and abilities are attained through possession of a Bachelor's Degree in Nursing or related field, and three (3) years of professional experience in a managed care/HMO, complex hospital or ambulatory care setting of which a minimum of two (2) years has been in an administrative or supervisory capacity with knowledge of QA and/or UM issues.


A Master's degree in Nursing or Health Care Management may substitute for one (1) year of experience.

Knowledge of:
•County, state, and federal legislation and regulations applicable to patient care and health maintenance organizations;
•Medi-Cal regulations, industry standards, Knox-Keene licensure requirements and resources for researching legislative issues;
•Organization and functioning of hospitals, emergency departments, and ambulatory care clinics;
•Principles of organizational, personnel and fiscal management within the health care industry and managed care systems;
•Computerized management systems including on-line information and telecommunications systems;
•Medical Terminology, current ICD coding and current standards in medical and nursing practice.
Ability to: •Organize, direct, coordinate and evaluate case management and utilization management functions in relation to health maintenance organization services, policies and procedures to ensure high quality patient care and conformity with prescribed laws, regulations, and standards;
•Work cooperatively with administrators, service providers, patients, and others to obtain and evaluate information and to implement necessary changes identified by the UM process;
•Prepare complex and detailed reports and procedures;
•Develop and analyze data and maintain accurate records;
•Supervise, monitor, train, and evaluate staff;
•Communicate effectively both orally and in writing;
•Manage diverse and conflicting priorities and projects in an effective manner;
•Maintain up-to-date knowledge of case management and utilization management practices and trends.

VETERANS PREFERENCE INFORMATION: Any veteran who has submitted a copy of their DD214 form, and received a discharge of other than dishonorable, from the armed forces showing service in any branch of the United States military will be given a preferential credit of five percent (ten percent for those identified as disabled veterans), after attaining a passing examination score for a numerically scored examination, as applicable by Memorandum of Understanding.

THE EXAMINATION PROCESS: The examination process may include one or more of the following: application review, application appraisal, preliminary competitive rating, performance test, written test, and/or oral interview examination.

This recruitment may require completion of Supplemental Questions in order to evaluate your education, training and experience relative to the required knowledge and abilities for the position you are applying for.

Your responses to the questions may also be reviewed and scored in a Competitive Rating evaluation process based on pre-determined rating criteria. Your answers should be as complete as possible, as no additional information will be accepted from applicants once the Competitive Rating evaluation has begun.

*New Hires shall be subject to a pre-employment criminal background check.

DISASTER SERVICE WORKERS: Under California law, all County employees are designated as Disaster Service Workers (DSW). In the event of a catastrophic event, County employees may be expected to fulfill emergency action assignments. As DSW's, they may be assigned to assist in any disaster service activity that promotes the protection of public health and safety and preservation of lives and property.

INFORMATION ON PERS CONTRIBUTION: For new members, salaries above a limitation imposed by federal law (that limit per IRS is $121,388 for 2018): (1) neither the County nor the employee makes contributions to PERS on the portion of salary that exceeds the limit, and (2) the portion of the salary that exceeds the limit is not used by PERS to calculate the retirement benefit. If you were a member prior to January 1, 2013, the limit is $275,000 for 2018.

If interested, please apply by Friday, November 30, 2018, 11:59 P.M. (PST) through the following link:

https://www.governmentjobs.com/careers/santaclara/jobs/2210508/vhp-utilization-management-manager

Time:  Full time
Salary:  Salary
Category:  Clinical/pharmacy/quality

Updated: 10/17/2018 3:36:31 PM