Supervisor, Utilization Management

Salary Range: $85,740 - $128,610
The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.

FLSA Status:Exempt
Department:Health Services
Reports To:Health Services Management

The Supervisor of Utilization Management is responsible for the oversight of daily operations of the Utilization Management (UM) activities, including the development and implementation of new programs related workflows, serving as a resource for internal departments, members, providers, delegates and community partners. In addition, the Supervisor of Utilization Management is responsible for supervision of the administrative staff to ensure that all UM functions are performed accurately and efficiently and in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements for all lines of business.

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

1. Develop, implement and supervise UM operation workflows to ensure compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures and business requirements for all lines of business.
2. Prepare and analyze operational and regulatory required reports prior to submission.
3. Support internal training efforts, including providing input in the development and implementation of training materials.
4. Monitor workflows and serve as initial point of contact for staff regarding escalation of complex issues; research, troubleshoot and resolve issues using available resources within established guidelines and ensure appropriate resolution, escalation, and/or follow up within specified timeframes. Escalate as appropriate to management.
5. Participate in intradepartmental management team meetings as needed. Frequently strategize with others in Quality, UM, Pharmacy, G & A, and Health Education ensure overall optimal performance of the Health Plan Services department.
6. Serve as the liaison between SCFHP internal departments and outside organizations including, but not limited to hospitals, vendors, and delegated medical groups to resolve authorizations related to eligibility and claims.
7. Identify issues and trends (data, systems, member, provider, other), as well as general departmental questions/concerns; report relevant information and recommendations to management.
8. Follow established Health Services policies and procedures and use available resources to respond to member and/or provider inquiries and resolve concerns in an accurate, timely, respectful, professional and culturally competent manner.
9. Collaborate with the Manager of Utilization Management on routine and ad hoc audits including the development, implementation and monitoring of corrective action plans.
10. Act as back-up to Medical Management Coordinators during times of high volume work and/or staffing shortages to ensure compliance with all applicable state and federal regulatory requirements.
11. Develop effective and professional working relationships with internal and external stakeholders and partners. Communicate effectively with members and providers orally and in writing.
12. Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions.
13. Attend off site meetings or events as necessary.
14. Perform other duties as required or assigned.

Carries out supervisory/management responsibilities in accordance with the organization's policies, procedures, applicable regulations and laws. Responsibilities include:

1. Recruiting, interviewing, and hiring.
2. Developing a high performing department culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives.
3. Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance.
4. Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees' needs, ensuring they have the necessary resources to do their work.
5. Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews.

The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

1. Associate's Degree in a Healthcare related field, or equivalent experience, training or coursework. (R)
2. Knowledge of health plan benefits, processes and operations related to commercial, Medi-Cal and/or Medicare programs. (R)
3. Minimum three years of experience in managed care or in a health care setting in positions requiring interaction with members and/or providers, two years of which involved progressively responsible experience involving direct Utilization Management responsibilities. (R)
4. Minimum one year of experience in a supervisory or lead capacity. (R)
5. Ability to lead by example and monitor workflows to support the staff by serving as the initial point of escalation regarding the handling of complex issues. (R)
6. Ability to understand, interpret, and apply applicable rules and regulations, and establish and evaluate priorities. (R)
7. Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R)
8. Ability to work within an interdisciplinary team structure. (R)
9. Ability to work weekends and company holidays as needed based on business and regulatory requirements. (R)
10. Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R)
11. Proficient in adapting to changing situations and efficiently alternating focus between telephone and non-telephone tasks to support department operations as dictated by business needs. (R)
12. Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific utilization management programs. (R )
13. Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
14. Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing. (R)
15. Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills. (D)
16. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
17. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
18. Ability to maintain confidentiality. (R)
19. Ability to comply with all SCFHP policies and procedures. (R)
20. Ability to perform the job safely and with respect to others, to property and to individual safety. (R)

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:

1. Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
2. Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
3. Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
4. Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
5. Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
6. Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

General office conditions. May be exposed to moderate noise levels.

EOE