Utilization Management Manager, Medicare Advantage - RN

Take on a high-impact role within a world-class health organization. Help drive the continued delivery of exceptional patient care. Take your career to the next level. You can do all this and more at UCLA Health.

As a Manager for Medicare Advantage Utilization Management, you'll provide direct management to a team of UM coordinators and nurses. You'll work closely with Medicare Advantage leadership to plan, execute, and manage various initiatives related to UM administrative, operational, and strategic objectives. You'll demonstrate leadership and effective communication by fostering collaborative relationships with peers, co-workers, and staff. You'll be responsible for overseeing and coordinating the following major functions:

• Pre-service Authorizations/Denial Letters
• Concurrent Review
• Continuity of Care
• Retro Claims
• Retrospective Review
• Referral Automation Business Rules/Configuration

We're seeking a self-motivated, detail-oriented, service-driven leader with:

• Current unrestricted RN licensure in CA required
• Bachelors of Science, Nursing (BSN) degree required
• Five or more years of utilization management required
• Four or more years of managerial experience required
• Four or more years of clinical experience providing direct patient care
• experience in an HMO environment
• Thorough knowledge of health care industry, utilization review, utilization management, and concurrent review ACM/CCM preferred
• Knowledge of Health Plan, DMHC, CMS, HIPPA and NCQA requirements
• Familiarity with CPT-4, ICD-10, and HCPCS codes
• Proficient computer skills including Internet search capabilities, Microsoft Word, Excel and Managed Care software (i.e. EZ Cap, Diamond, IDX)
• Strong critical thinking, problem solving, and analytical skills
• Excellent communication, organizational, and prioritizing skills required
• Ability to develop, implement, and evaluate methods and systems to improve efficiency
• Ability to lead and facilitate cross-functional workgroups and other meetings
• Skill in working with complex organizations to comply with regulatory requirements
• Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, health plan requirements and State/Federal regulations
• Ability to analyze and organize complex federal and private insurance regulations
• Ability to travel/attend off-site meetings and conferences
• ACM - Accredited Case Manager preferred
• CCM - Certified Case Manager preferred

Named one of the top hospitals in the nation by U.S. News & World Report, UCLA Health features four award-winning hospitals and more than 250 community clinics throughout Southern California as well as the David Geffen School of Medicine. If you're looking to experience greater challenge and fulfillment in your career, you can at UCLA Health.