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Manager- Utilization Management & Pharmacy Benefit Administration (UM/PBA)- / Sharp Community Medical Group (SCMG) / San Diego / Full Time / *Sign-on/Relo Bonus $8k / Referral $2k

Job ID JR123160 Date Posted 07/07/2022
San Diego, California
  • Corporate Offices
  • Day
  • Regular
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Shift Start Time:

8 AM

Shift End Time:

5 PM

Additional Shift Information:

Weekend Requirements:

As Needed

On-Call Required:


What You Will Do
Under the direction of the Sharp Community Medical Group (SCMG) Health Services (HS) Director and in collaboration with the Health Services leadership team, this position is accountable for the development and implementation of an effective Utilization Management program that encompasses a patient centered care management approach that includes referral management, prior authorization, Case Management and Chronic Care Management and Pharmacy Benefit Administration.
Oversees the operations of the Utilization Management (UM) Department and is responsible for the execution and coordination of all UM activities including Pharmacy Benefit Administration (PBA).
Helps to plan, develop, organize, monitor, communicate and recommend modifications to the UM Program and Pharmacy Benefits Program including all UM and Pharmacy policies and procedures.
Coordinates interdepartmental projects to assure quality outcomes.
Develops and implements operational policies and procedures that have a direct impact on the UM program in accordance with NCQA standards, legislative, and contracted health plan requirements.
Provides direct supervision of the UM staff and models effective leadership and mentoring skills. Promotes staff development using the concepts and tools supporting the Sharp Experience.
Collaborates with Sharp Management team to facilitate internal and external committees and/or initiatives to address quality improvement as a representative of SCMG.
Provides support to the Director HS and HS leadership team to ensure regulatory and legislative compliance for the Department.
Under the direction of the SCMG HS Director, develops financial (budget) and operational strategy of UM Department.

Required Qualifications

  • Bachelor's Degree in Nursing or Healthcare Administration.
  • 5 Years clinical experience in acute hospital care.
  • California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED

Preferred Qualifications

  • Master's Degree in Nursing, healthcare, quality, or business.
  • 5 Years clinical nursing experience in acute care hospital setting.
  • 2 Years management, service line or program experience.
  • Certified Professional in Healthcare Quality (CPHQ) - National Association for Healthcare Quality -PREFERRED
  • Certified Case Manager (CCM) - Commission for Case Manager Certification -PREFERRED

Other Qualification Requirements

  • Other relevant QM/UM/CM certification preferred

Essential Functions

  • Supervisory
    Develops and implements policies and procedures that have direct impact on the UM and PBA Departments in day to day operations.
    Provides direction and leadership to the Referral Processing, Prior Authorization staff and Case Management and Chronic Care Management and Pharmacy Benefit staff.
    Direct oversight of onsite Physician Management Model (PPMM)
    Promotes consistency, communication, fairness and respect within the department for all employees.
    Adheres to Sharp Healthcare human resources policies and ensures timely evaluation for employees per Sharp Healthcare policies.
    Establishes goals and objectives for each direct report in compliance with performance management policies.
    Maintains consistent follow-up with direct reports to support attainment of goals set.
    Develops, facilitates and updates training programs throughout SCMG to ensure staff has knowledge that allows them to complete their assigned tasks.
  • Compliance
    Manages UM and PBA operations in accordance with National Committee on Quality Assurance (NCQA) and Health Plan requirements and ensures that new requirements are identified on a timely basis
    Collaborates with SCMG Management and HSM Management staff in quality related activates to ensure compliance with health plan contracts, legislative policies and SCMG specific requirements.
    Works with SCMG Management, HSM Management and HSM staff to identify issues and initiate improvements.
    Works with HSM Director to ensure timely submission of required Utilization Work plans to Health plans; if required submits corrective action plans within agreed upon time frames.
    Ensures appropriate and timely compliance with provider credentialing
    Develops and enforce policies and procedures for HSM that involve UM and Case Management.
    Serves as the SCMG UM liaison to outside compliance agencies to ensure collaboration with other Med Groups and Health plans (i.e. ICE, IHA, NCQA)
  • Financial

    Develops, monitors, and maintains unit budget within approved limits.
    Responsible for identification and implementation of cost savings strategies.
    Maintains an excellent understanding of health plan incentives targeted at efficiency measures, i.e. Pay for Performance, health plan specific programs, etc. and implements processes to achieve SCMG targets.
    Supports development and implementation of initiatives and strategies targeted at maximizing group performance in incentive programs such as IHA’s Pay for Performance Program.
  • Reporting and Data Analysis
    Implementation and maintenance of a regular reporting system for operational and quality outcome indicators.
    Analyzes and implements actions plans using these reports to measure and improve patient care outcomes and operational efficiency and effectiveness.
    Reports key performance measurement and quality improvement initiative results to the Quality of Care Committee.

Knowledge, Skills, and Abilities

  • Demonstrated working knowledge of managed care, capitation, provider payment mechanisms and member benefits.
  • Demonstrated experience and the ability to lead staff and daily operations.
  • Demonstrated ability to develop, implement and monitor program direction and continuous performance improvement initiatives.
  • Excellent written and verbal communication skills, customer service skills and leadership skills.
  • Strong working knowledge of clinical practice and medical necessity guidelines.
  • Strong analytical, problem solving, concurrent and retrospective data management and computer skills.
  • Ability to establish good working relationships with all levels of support staff, providers, administrative staff and all other internal and external customers.
  • Demonstrated positive personal influences on teams and customers including the willingness to accept change proactively.
  • Demonstrated ability to be flexible and responsive to needs of organization and possess ability to balance the needs of multiple priorities.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class

Certified Case Manager (CCM) - Commission for Case Manager Certification; Certified Professional in Healthcare Quality (CPHQ) - National Association for Healthcare Quality; Master's Degree; California Registered Nurse (RN) - CA Board of Registered Nursing; Bachelor's Degree
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