People are the most important asset of Imperial, for this reason the difference and plurality of people, equality of opportunities, non-discrimination and inclusion in the workplace are priority and strategic factors in the Organization. Imperial maintains a strong will to promote Diversity, Equity, and Inclusion, through inclusive leadership as a lever change and business sustainability.

Imperial Health Plan of California, Inc., is licensed by the California Department of Managed Health Care as a health care service plan in accordance with the Knox-Keene Act to provide Medicare Advantage covered services, including a Medicare Advantage Prescription Drug plan, and a Chronic Condition Special needs plan over numerous counties in California. Through its affiliates, Imperial Insurance Companies, Inc., and Imperial Health Plan of the Southwest, Inc., it also offers individual marketplace covered services in Texas, Utah, Nevada and Arizona.

Mission is to deliver valuable care so that members are healthy in body, mind, and spirit to achieve their inherent potential.

Vision is to deliver value based care that is clinically effective, sustainable, and achieves exceptional outcome. Please be sure to check our company website at https://imperialhealthholdings.com

JOB SUMMARY: Responsible for providing operational leadership to the day-to-day function of the UM/Prior Authorization and Inpatient Teams. The UM Manager will ensure that the team complies with Federal, State, Health Plan and NCQA requirements.

ESSENTIAL JOB FUNCTIONS:

1. Collaborating with clinical and non-clinical personnel providing timely care which complies with generally accepted standards of clinical practice.

2. Assigns work schedules, delegates reviews, provides direction on review priorities, meets the demands of internal and external partners, and ensures staff achieve performance goals and adherence to company policies.

3. Ensures that the UM team is properly trained to conduct medical necessity reviews on incoming pre-service/prior authorization, on routine and expedited referrals requests in compliance with Federal, State, Health Plan and NCQA standards.

4. Ensures UM team documents on the medical management system timely, all supporting clinical information, outreach attempts and criteria used to make a determination.

5. Monitors, tracks, and reports any inappropriate referral patterns to the UM Medical Director and Director of Clinical Services

6. Serves as a subject matter expert on appropriate use, interpretation and documentation of clinical criteria in the review process using NCD, LCD, Health Plan Medical Guidelines, MCG, NCCN, etc.

7. Conduct inpatient huddles to review inpatient census including Inpatient CMs and CMO to discuss cases and discuss barriers of discharge plannings.

8. Conduct Annual IRR Reviews for clinical staff by using selecting case studies via MCG Learning Module.

9. Conduct Annual IRR Reviews for non-clinical staff by administering quiz.

10. Prepare and participate in UM audits.

11. Develop and revising UM program, workplans and policies and procedures.

12. Prepare and update quarterly, semi-annually and annual um workplans.

13. Participate in MSC meetings and other meetings as needed.

14. Prepare and submit compliance reports related to UM activities.

15. Correspond promptly to health plan requests that are related to UM activities.

16. Facilitates an atmosphere of interactive management and the development of collegial relationships among personnel and others, serving as a link between clinical and the healthcare disciplines

17. Collaboration with clinical personnel and members of other disciplines, participates in an organizational policy and procedure formulation and decision making, accepts organizational accountability for services provided, and evaluates the quality and appropriateness of care.

EDUCATION/EXPERIENCE:

· Bachelor’s degree in a health care related field

· At least 2 years of management experience in a Medical Group, MSO, Hospital, or Health Plan setting

· At least 5 years of experience in UM/Managed Care setting

SKILLS/KNOWLEDGE/ABILITY:

· Proficient in Microsoft Office

LICENSURE/CERTIFICATE/TRAINING:

· Current unrestricted RN or LVN in the State of California, additional licenses in State of Texas and Arizona will be a plus

Imperial Health Plan of California, Inc.

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Manager UM Clinical Services