RN Job

Director, Utilization Management

Full-time
Req #7944
Los Angeles, 90017

Main responsibility includes: regulatory compliance, accreditation compliance, assistance with oversight of Plan Partners and Delegated Provider Groups related operations, oversight vendor's related delegated functions, operations for direct lines of business and/or management services agreement functions, and interfacing with external agencies including other Local Initiatives, Plan Partners and external organizations. 

General essential functions include responsibility for maintain an operationally compliant UM Department that ensures that services are completed in the required timeframe and that patient and provider services are delivered appropriately.  The internal health plan operations include: utilization review (prospective, concurrent and retrospective), Liaison of delegate’s UM elegation and Appeals and grievance-related functions.

Qualifications
  • Education Required Bachelor's Degree in Nursing
  • Education Preferred Master's Degree in Nursing
  • At least 7 years experience in implementing and managing of Medicaid and Medicare program requirements with 5-7 years of supervisory/management experience in a health care/health plan environment. 
  • Experience in obtaining and sustaining National Committee for Quality Assurance (NCQA) accreditation. 
  • Experience in Medicare-SNP programs.
  • Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License
  • Licenses/Certifications Preferred Required TrainingRegistered Nurse (RN)
About the Hospital

As the nation's largest publicly-operated health plan, we have a great responsibility to the communities we serve, and our employees play an essential role in ensuring we meet those needs.

Why Join Us?
Opportunity. Amazing co-workers. A supportive management team. Great compensation and benefits. Camaraderie and a true sense of mission. If you want a career that truly contributes to the good of all, join us as we work towards a healthier L.A.

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