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Manager Utilization Management/PBA

Send to my Email Email a friend Job ID 74421 Date posted 06/25/2016
Requisition ID: 74421
  • Facility: Sharp HealthCare
  • City: San Diego
  • Department: SCMG Utilization Management
  • 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 day shift, 8:00 am - 5:00 pm
Required Skills and Qualifications
  • Current unencumbered California Registered Nurse license
  • Bachelor’s degree in Nursing or Healthcare Administration
  • 5 years clinical experience in the acute hospital care
  • Demonstrated working knowledge of managed care, capitation, provider payment mechanisms and member benefits
  • Demonstrated experience and 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
Preferred Skills and Qualifications
  • Master’s degree in nursing, healthcare, quality or business
  • 2-3 years of management, service line or program experience
  • Certified Professional in Healthcare Quality (CPHQ), Certified Case Manager (CCM) or other QM/UM/CM certification

Under the direction of the Sharp Community Medical Group (SCMG) Health Services (HS) Director and in collaboration with the Health Services leadership team, the Manager UM 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.
The Manager oversees the operations of the Utilization Management (UM) Department and is responsible for the execution and coordination of all UM activities including Pharmacy Benefits.  Responsibilities include helping 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, coordinating interdepartmental projects to assure quality outcomes, and developing and implementing operational policies and procedures that have a direct impact on the UM program in accordance with NCQA standards, legislative, and contracted health plan requirements.  The Manager UM will provide direct supervision of the UM staff and models effective leadership and mentoring skills, promote staff development using the concepts and tools supporting the “Sharp Experience” and collaborate with Sharp Management team to facilitate internal and external committees and/or initiatives to address quality improvement as a representative of SCMG.  The role also includes providing support to the Director Health Services (HS) and Health Services leadership team to ensure regulatory and legislative compliance for the Department and under the direction of the SCMG HS Director,  the Manager develops financial (budget) and operational strategies of the UM Department. 
Sharp Community Medical Group (SCMG) is one of the state's largest and most successful IPAs. Established in 1989, it has over 150,000 members and is comprised of 200 primary care physicians and 500 specialists. The Health Services division of SCMG coordinates the medical care of members for inpatient and outpatient services and has a staff of over 100 nurses, coordinators and support personnel to manage utilization review, case management and quality improvement functions.
Essential Physical Requirements may include
  • Bending
  • Lifting
  • Reaching
  • Ability to sit for extended periods at desk, computer terminal and/or meetings
  • Use of personal automobile to meet with providers, health plans and attend meetings
Additional physical requirements of position 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: Manager Utilization Management, UM, Registered Nurse, Management Job, Nursing Leadership, RN Case Management, Case Manager, Quality, Performance Improvement, Nursing Jobs, Sharp Community Medical Group, SCMG, San Diego
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