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Lead Medical Management, Health Services, SHP

Job ID 83102 Date posted 10/03/2017
  • Facility: Sharp HealthPlan
  • City: San Diego
  • Department: Health Services
  • Category: Nursing Management Jobs
  • Job Status: Full-Time
  • Shift: Day Job
  • FTE: 1.0
  • Shift Start: 8 AM
  • Shift End Time: 5 PM
This position is located in Kearny Mesa, CA (San Diego County)
8-hour shift: 8:00 am – 5:00 pm, weekends as needed.
Required Skills and Qualifications
  • Current unencumbered CA RN license
  • Utilization Management/ Case Management experience preferably in a health plan, medical group or HMO setting
  • Strong working knowledge of referral management, regulatory and legislative requirements surrounding referral processing, denials, and other referral correspondence
  • Thorough knowledge of managed care, UM, CM, the division of financial responsibility (DOFR) between health plans and medical group and contractual agreements with providers and Strong clinical knowledge
  • Excellent knowledge of benefits and covered services
  • Ability to contribute creative and innovative ideas to help achieve applicable goals and objectives of the UM and CM Programs and Work Plans
  • Strong ability to analyze information or data to identify adverse trends or problems, offer suggestions for corrective actions, implement corrective action plans, and perform ongoing monitoring and skilled in conflict management
  • Excellent organizational and time management skills with ability to multitask
  • Ability to work independently in research and decision making with minimal direction   Excellent communication skills with ability to communicate in a clear, succinct, professional manner, both verbally and in writing with all levels of staff, management, and medical directors
  • Working knowledge of HMO contracts, Medicare, health plan regulatory criteria/guidelines
  • Proficiency in use of Microsoft Outlook, Word, and Excel
Preferred Skills and Qualifications
  • Supervisory experience   
  • BSN or Bachelor's Degree in a related field
  • Utilization Management, Case Management, or Professional in Healthcare Quality (CPHQ) certification  

The Lead Medical Management will manage the day to day operations of the SHP Medical Management program by providing supervision and leadership to the Medical Management  team to ensure timely, effective, appropriate and high quality case management(CM) and utilization management(UM)  that includes concurrent, prospective and retrospective review.  The Lead will be responsible for operational planning consistent with existing policies and/or principles, managing medical management activities to include tracking, trending, and analyzing data, facilitation of provider education, supporting the medical directors and collaborating with other departments such as Customer Care, Provider Relations, Compliance and Claims.  The Lead will participate in the development of the annual UM/CM plan and implementation of corrective action plans related to audits and requirements of NCQA and other regulatory requirements.  Responsibilities include collaborating with the compliance department to effectively integrate and implement processes consistent with health plan requirements, NCQA, regulatory compliance, DMHC and CMS.    The Lead Medical Management will also develop and implement new programs under the direction of the Manager of Medical Management.
Here's what Sharp Health Plan has to offer you:
Sharp Health Plan is the largest, locally-based commercial health plan in San Diego. We are a not-for-profit organization serving the needs of San Diegans since 1992. As a subsidiary of Sharp HealthCare, San Diego’s largest provider of health care services, we not only serve the people of San Diego, we are the people of San Diego.
Through our unique integration with Sharp HealthCare, we connect our members to an award-winning network of hospitals, medical groups and physicians. We offer health insurance options for individuals, families, groups and businesses that combine affordability, choice, high-quality health care and personal service.
Sharp Health Plan is the highest member-rated Health Plan among reporting California Health Plans.*  We're also accredited by the National Committee for Quality Assurance (NCQA) with a status of Commendable which is awarded to organizations with well-established programs for service and clinical quality.  We continually strive to improve the quality of our services and benefits, and seek innovative solutions to today’s complex health care issues.  From helping you find the right health plan to the right doctor to being a great place to work, we’re here for you!
If you like the sound of what it means to be a Sharp Health Plan team member, and you meet the qualifications above, please submit your resume along with a brief explanation about why you would be a good fit for this position. We look forward to hearing from you.
*The source for this data is Quality Compass® 2016 and is used with the permission of the National Committee for Quality Assurance (NCQA). Quality Compass® 2016 includes certain CAHPS® data.
Essential Physical Requirements may be discussed during interview.
Sharp HealthCare is proud to be an Equal opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, gender identity, transgender status, sexual orientation, protected veteran status or any other protected class.
Keywords:  83102, Lead Medical Management Jobs, RN Supervisory Jobs, RN Leadership Jobs, Utilization Management Jobs, UM Jobs, Case Management Jobs, RN Case Manager jobs, RN Jobs, NCQA, CPHQ, CCM, Healthplan Jobs, HMO, Provider Relations, Nursing Jobs in San Diego, San Diego Jobs

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