Medicare Utilization Management Program Manager
Medicare Utilization Management Program Manager - RN
Under the direction of the Corporate UM Director and the Chief Medical Officer - VP Medicare, this position is responsible for complex tasks, supporting multiple projects and programs including tracking, project coordination, data management, document management. This position works with Medicare UM leadership to implement Quality initiatives within the department. Ensures compliance with accrediting and regulatory agencies and prepares for audits as necessary. May perform specialized UM functions such as: Policy and procedure development; analysis of utilization trends and reports; development of Medicare UM processes and guidelines to strengthen overall operational delivery and outcomes of Medicare services. Develops communications/presentations; and other projects as needed. This position is 100% responsible for activities that support Medicare membership goals and objectives.
• Partnership with the Corporate Director of Utilization Management and CMO-VP Medicare/ABD LTC, to organize and maintain medium to large scale projects, including documentation of project proposal, project scope, project plan, time lines and reporting.
• Analyze, interpret, communicate and apply regulatory documents. Prepare reports and presentations for management, committees and external organizations as required.
• Develop and update the Medicare Advantage policies/procedures for the Utilization Management Program, including charters, workplans, and program descriptions as assigned. Able to analyze, apply, interpret and communicate policies, procedures and regulations effectively to meet regulatory and accreditation requirements. Maintain, update and oversee Medicare related UM Policies, UM training materials, UM Program document template language and UM Program working documents.
• Participate and make recommendations for process improvements in work organization, communication and efficiency with internal and external customers.
• Schedule workgroup meetings across all Medicare Plans, prepares distributes agendas, presentations, takes minutes, follow-up on actions items
• Initiate, investigate, prepare and maintain Medicare UM support functions to ensure compliance with NCQA, CMS regulatory and other external agencies
• Develop annual workplan to support Medicare strategic goals and direction
• Work in partnership with Medicare UM team to develop appropriate and consistent processes across all Medicare units
• Conduct Quality audits across all Medicare Plans as appropriate
• Work with Corporate and Medicare training to develop and maintain training program for Medicare
• Work with the Corporate Director of Utilization Management to develop annual budget.
• Conduct meetings as required
• Detail oriented
• Strong project management skills
• Ability to work in multi-disciplinary teams
• Superior interpersonal skills
• Ability to perform independently, while handling multiple projects simultaneously,
• Strong analytical and problem solving skills
• Must be knowledgeable of NCQA and CMS standards
• Excellent attendance and professional attitude. Comprehensive knowledge of healthcare customer service, regulatory requirements and appeal process.
• Complies with required workplace safety standards
• Excellent verbal and written communication skills
• Ability to abide by Molina’s policies
• Maintain regular attendance based on agreed-upon schedule
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers
Required Education:
Degree in Nursing, Health Care/Health Promotion, Health Care Administration, or equivalent experience.
Preferred Education:
Preferred Bachelor’s Degree or equivalent work experience.
Required Experience:
3-5 years of Managed Care experience, including one or more of the following: UM, CM, QI, DM, Health Education Minimum of two (2) years utilization management and case management experience with quality improvement experience.
Knowledge and recent experience with CMS Medicare Requirements
Minimum of two (2) years experience in leadership role, including experience in supervising, training, and evaluating clinical staff
Prior program development, monitoring, and evaluation experience are highly preferred.
Knowledge of appropriate regulatory and accreditation requirements.
Strong NCQA and CMS knowledge
Knowledgeable in case management software systems and Microsoft Office suite of applications is desirable.
Clinical Writing Skills required
Required Licensure/Certification:
Current active, unrestricted RN license required.
Preferred Licensure/Certification:
Preferred CCM, CPHQ, CPHM
Molina Healthcare is an Equal Opportunity Employer. (EOE). M/F/V/D