Registered Nurse - Utilization Review

Registered Nurse-Utilization Review

Job ID #1762302

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About this Role

The Manager of Utilization Management (UM) is responsible for the direct oversight of internal and external delegated UM functions including the development and implementation of policies, procedures and program development and related quality monitoring. In addition, the Manager of UM is responsible for supervising the Supervisor of UM to ensure that all administrative UM processes are performed in accordance with all applicable state and federal regulatory requirements.

Job details

$60.00 / hour

San Jose, California

New

Profession : Registered Nurse

Facility Type : ???

Specialty : Utilization Review

Division : MedFi

Start Date : 03 / 10 / 2025

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Responsibilities

1. Develop, implement and manage all UM processes for continuous and sustained compliance with all applicable state, federal and NCQA regulatory requirements, SCFHP policies and procedures and general business requirements for all lines of business.

2. Develop and implement continuous analysis and quality monitoring of all policies and procedures to evaluate UM staff performance and ensure regulatory compliance

3. Ensure the integration of UM operations into other internal and external teams / departments including Quality, Long Term Services and Support (LTSS) and Behavioral Health (BH).

4. 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.

5. 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.

6. 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.

7. 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

Required Qualifications

1. Unrestricted professional RN licensure in the state of California.

2. Minimum two years of experience in a supervisory capacity in a managed care setting.

3. Understanding and / or experience with Utilization Management.

4. Must be knowledgeable of DHCS, CMS, DMHC regulations and NCQA regulatory Population Health standards.

5. Ability to consistently meet accuracy and timeline requirements to maintain regulatory requirements.

6. Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs