Utilization Management Market Operations Manager

Job Summary:

The Utilization Management (UM) Market Operations Manager is responsible for the operational activities of UM and Appeals for a specified line(s) of business managing the development of policies and procedures, review of team metrics, statutory reporting, overseeing committee reviews, audit preparation and presentations, and preparation and presentation of annual program requirements.

Essential Functions:

• Utilize process controls to achieve operational excellence in all areas within the department
• Actively work with clinical leadership in closing variances of operational procedures
• Oversee and support the development and maintenance of staff resources including but not limited to policies and standard operating procedures that ensure departmental alignment and adherence to contractual, state, NCQA, federal and other applicable guidelines
• Drive process improvement by utilizing continuous improvement frameworks
• Manage policy and process changes that result from regulatory/compliance requirements
• Educate, mentor, and train staff and clinical leaders on requirements, process improvement and quality
• Manage various relationships with both internal and external partners to improve standardization and interdepartmental collaboration on enterprise goals and initiatives
• Work collaboratively with appropriate departments to define and utilize outcome measurements in defining and driving success
• Design future state operation models that address opportunities
• Manage cross-divisional and cross-functional process improvement opportunities such as new business, systems and delegations
• Oversee and support change management initiatives that impact the department
• Perform any other job duties as requested

Education and Experience:

• Degree or diploma in nursing is required
• A minimum of five (5) years of experience in UM or related operations related to the responsibilities of this position is required
• Managed Care experience is required
• Experience with analysis, data and reporting is required
• Accreditation, auditing, and process improvement experience is preferred
• Demonstrated change management and continuous improvement leadership skills required
• Previous experience with quality control and/or process standards preferred
• Nevada license is HIGHLY preferred
• Appeals experience is HIGHLY preferred

Competencies, Knowledge and Skills:

• Proficient use of Microsoft Office Suite, to include Word, Excel, PowerPoint, Outlook, and Visio knowledge with a strong willingness to learn
• Fluent in NCQA and/or CMS, accreditation and audit standards with knowledge of regulatory reporting, compliance requirements, and auditing procedures
• Decision making/problem solving and critical thinking skills
• Planning, problem identification and resolution skills
• Strong oral, written and interpersonal communication skills
• Responsive to a changing environment/change resiliency
• Proficiency with quality improvement, performance improvement and operations
• Ability to develop, prioritize and accomplish multiple competing goals
• Strong collaboration skills with ability to work with multi-disciplinary departments
• Ability to work independently and within a team
• Strong attention to detail and time management skills
• Customer service oriented with de-escalation skills
• Ability to gather/analyze data and create meaningful action items
• Ability to review and implement evidence-based trends

Licensure and Certification:

• Current, unrestricted Registered Nurse (RN) licensure is required
• Six Sigma or project management certifications are a plus

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business