Manager of Utilization Management, Los Angeles, CA
APLA Health’s mission is to achieve health care equity and promote well-being for the LGBT and other underserved communities and people living with and affected by HIV. We are a nonprofit, federally qualified health center serving more than 14,000 people annually. We provide 20 different services from 15 locations throughout Los Angeles County, including: medical, dental, and behavioral health care; PrEP counseling and management; health education and HIV prevention; and STD screening and treatment. For people living with HIV, we offer housing support; benefits counseling; home health care; and the Vance North Necessities of Life Program food pantries; among several other critically needed services. Additionally, we are leaders in advocating for policy and legislation that positively impacts the LGBT and HIV communities, provide capacity-building assistance to health departments across the country, and conduct community-based research on issues affecting the communities we serve.
For more information, please visit us at aplahealth.org.
APLA Health offers great benefits, competitive pay, and a collaborative working environment!
- Medical Insurance
- Dental Insurance (no cost for employee)
- Vision Insurance (no cost for employee)
- Long Term Disability
- Group Term Life and AD&D Insurance
- Employee Assistance Program
- Flexible Spending Accounts
- 10 Paid Holidays
- 3 Personal Days
- 10 Vacation Days
- 12 Sick Days
- Metro reimbursement or free parking
- Employer Matched 403b Retirement Plan
If you are looking for an opportunity to make your mark then this is the position for you! This is a great opportunity to make a difference!
This position is responsible for the management of the daily operations for the Utilization Management (UM) for APLA Health and Wellness (APLAHW). This position will ensure that all processes, programs and operations of utilization management are fully implemented for APLAHW.
The Manager of UM will be proactive in establishing collaborative working relationships with each member of the Care Delivery team to assure a sound Utilization Management Program.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Develops and Implements a standardized Utilization Management Program to ensure that all functions meet internal, Government, Health Plan, and regulatory requirements.
- Ensures staff competency utilizing inter-rater reliability tools and evidence-based criteria for utilization review.
- Develop, implement and maintain compliance, policies and procedures regarding medical utilization management functions.
- Establishes excellent working relationships with all internal/external constituents and staff, including the Chief Medical Officer and medical directors. Promotes collaborative relationships.
- Participates in the collection, analysis and reporting of data relevant to utilization management.
- Collaborates with the Director to identify opportunities for process improvements in Utilization management that are consistent with the organizations vision and strategic long term goals.
- Develop, implement, and maintain utilization management programs to facilitate the use of appropriate medical resources and decrease the business unit's financial exposure.
- Compile and review multiple reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management.
- Communicates with the staff both verbally and in writing to convey health plan, contract or operations information to ensure all staff members have a consistent and appropriate knowledge base to perform their duties.
- Promotes staff growth and development by identifying educational opportunities to increase efficiency and maintain compliance with industry standards.
- Participates in staff meetings, assuring policy and procedures are adhered to and when necessary modified to address changing strategic objectives.
OTHER DUTIES MAY BE ASSIGNED TO MEET BUSINESS NEEDS.
Training and Experience:
- Five (5) years utilization/care management experience in a clinical or managed care setting preferred.
- Four (4) years management/supervisory experience (in a formal or informal role) preferred.
- Registered Nurse with active California certification required. Requires either a Bachelors degree in Nursing or other Healthcare related field
- Basic computer skills in a Windows operating environment including Microsoft Word, Excel, and an e-mail system.
- Must be a dynamic leader, able to navigate a complex environment, with excellent verbal and written communication skills, as well as strong operations experience.
- Effective influencing, negotiation, relationship-building and communication skills are essential.
- Effective employee management skills.
- Possess strong leadership, critical-thinking and motivational skills/abilities.
- Excellent problem-solving and organizational skills required.
- Knowledge of InterQual and/or Milliman software.
- Knowledge of ambulatory healthcare delivery and management.
- Knowledge of NCQA, DMHC, CMS and other regulatory agency requirements pertaining to delivery of health care in the managed care setting.
- Ability and willingness to travel within APLAHW locations.
- Manage people through change.
- Demonstrate flexibility through change.
- Lead and form a collaborative team.
- Work effectively under pressure due to changing priorities.
- Independently and self-direct activities.
- Work effectively, establish, and promote positive relationships.
- Adapt quickly to changing conditions while managing multiple priorities.
WORKING CONDITIONS/PHYSICAL REQUIREMENTS:
This is primarily an office position that requires only occasional bending, reaching, stooping, lifting and moving of office materials weighing 25 pounds or less. The position requires daily use of a personal computer and requires entering, viewing, and revising text and graphics on the computer terminal and on paper.
Must possess a valid California driver’s license; proof of auto liability insurance; and have the use of a personal vehicle for work related purposes.
Equal Opportunity Employer: minority/female/disability/veteran.
Visit our website at www.aplahealth.org to apply or click the link below: