Manager, UM Regulatory & Compliance - CCA

1. Oversee the compliance, training, and quality assurance functions within the Utilization Management Out-Patient Services unit to ensure Utilization Management policy and protocol are being adhered to as outlined by DMHC and NCQA.
2. Maintain working knowledge of the DOFR related to both facility and professional components for all IPA’s.
3. Ensure all prior authorization activities meet content and delivery requirements. 
4. Issue and monitor Corrective Action Plans related to deficiencies of noncompliance. Develop action plans in accordance with identified issues.
5. Act as in-house expert regarding Utilization Management process. Ensure adherence and consistent application of non-clinical and clinical Utilization Management criteria always ensuring audit readiness.
6. Communicate and train Utilization management clinical and non-clinical staff and delegates on best practices and new regulations and requirements to ensure coordinated, continuous, cost-effective quality outpatient health care for Members and Providers.
7. Ensure Utilization Management processes are tested and validated when changes are made in the medical                management system.
8. Ensure all out-patient activities follow regulatory adherence (E.g., UM Call Center activities to COC, OG, OD, Provider redirection requests, Out-patient denials and member notifications are received, processed, and completed within regulatory timeframes).
9. Collaborate with the Medical Directors to ensure timely processing of referrals and denials.
10. Lead audit related activities (e.g., Monthly review of the referral universe, mailroom compliance for the Utilization Management mailing ensuring adherence to regulatory requirements).
11. Collaborate and communicate with management on issues and processes that impact Utilization Management and other organizational entities internally and externally.
12. Foster a fair work environment to assure that hiring, on-boarding and continued education is provided to staff to improve engagement, productivity, and quality. Coach and mentor staff to promote process improvement and to foster team culture.
13. Accountable for continued refinement and growth of staff development. Develop and implement training programs for staff.
14. Assure LEAN principles are utilized and PDSA cycles are performed for all UM department processes to assist in the transformation of becoming a 5 Star Health Plan.
15. Explore and implement processes to promote auto adjudication of service requests.
16. Design and develop Outpatient Utilization Management reports, such as staff productivity, authorizations approved/denied by line of business, dashboard reports, etc.; assures that the Supervisors of the above programs understand and use the reports effectively to manage the delivery of services.
17. Explore, promote, and coordinate implementation of new Utilization Management software and processes. Build tools and resources to handle new programs to provide state of the art care for IEHP Members.
18. Maintain internal and external policies and procedures relating to Utilization Management Out-Patient Services unit.
19. Provide open lines of communication with Utilization Management staff, IEHP delegates and providers on issues related to IEHP Utilization Management policies and procedures. Build strong collaboration and rapport with external delegates and internal teams and medical directors.  
20. Forecast and plan for future based on growth of the department.
21. Any other duties as required ensuring Health Plan operations are successful.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.