Utilization Management Market Operations Manager - RN Preferred - Must live in Nevada - Must hold NV license

$83,000 - $132,800 / year

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:

Associates degree in Nursing or advances degree is Psychology 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

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 or Licensed Psychologist in state of practice 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:

$83,000.00 - $132,800.00

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):

Salary

Organization Level Competencies

Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

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