Manager, Utilization Management Claims Review is responsible for overseeing clinical and operational functions of Claims Review team, providing leadership and strategic direction for accurate clinical claim determinations and regulatory compliance.
Requirements
- At least 6 years of experience in Clinical Nursing.
- At least 3 years of experience with Medi-Cal and Medicare in a managed care environment.
- At least 4 years of leading staff, supervisor/management experience.
- Experience in performing and creating clinical documentation.
- Experience in regulatory compliance for a health plan.
- Experience leading teams, projects, initiatives, or cross-functional groups.
- Strong leadership, coaching, and team development skills.
- Knowledge of medical necessity criteria, reimbursement principles, and managed care operation.
- Knowledge of clinical policies.
- Knowledge of CPT/HCPC Codes, and ICD-10.
- Proficient in claims processing systems and electronic medical record platforms.
- Strong problem-solving skills and the ability to identify discrepancies, assess risk, and recommend actionable solutions.
- Excellent verbal and written communication skills.
- Ability to work independently with a high degree of initiative, organization, and self-direction.
- Ability to work effectively with diverse teams in cross-functional work groups.
- Ability to multitask, re-prioritize tasking, and streamline day-to-day operations.
- High organizational and time-management skills.
- Familiarity with Centers for Medicare and Medicaid Services (CMS), Medi-Cal, or other regulatory frameworks.
- Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment.
- Ability to guide and support team members.
- Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.
- Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.
- Must have a deep understanding of financial principles.
- Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.
- Strong presentation skills.
- Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.
- Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.
Benefits
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
