This professional level Director position is responsible to direct and coordinate the planning, organization, implementation and evaluation of all activities and personnel engaged in Utilization Management (UM) Departmental operations. The Director is responsible for providing leadership and direction to the Utilization Management Department to ensure compliance with all local, state and federal regulations, that accreditation standards are current, and all policies and procedures meet current requirements. The Director is expected to serve as a liaison for numerous internal and external committees, workgroups, and operational meetings. Requires effective collaboration with other internal and external departmental leaders to ensure regulatory compliance and organizational implementation of continuous improvement activities to achieve appropriate utilization of health care resources.
Bachelor’s degree or equivalent work experience. Note equivalent work experience in lieu of a Bachelor’s degree will be approved by HR and the hiring manager. Relevant Master’s degree preferred. Current, unrestricted RN License to practice in the State of California is required. Minimum 5 years of utilization management experience in a managed care environment, preferably with Medicare and Medicaid populations. 5+ years of supervisory experience required. Organizational and managerial skills. California Medi-Cal and Medicare benefits, regulations and standards. NCQA and CMS standards, Quality Improvement studies, HEDIS reporting. Data collection and analysis, and management practices as related to quality of medical care. Proficiency in the use of computers and main-frame or web-based systems as well as Windows-based PC applications with emphasis on word processing and spreadsheet software; Oracle, MS Word and Excel preferred. Managerial skills. Proven organizational skills. Strong clinical skills.
Application Process: For a complete job description and to apply online, please go to www.caloptima.org. Questions can be directed to Julie Newman, Senior Recruiter, 714-246-8425 or firstname.lastname@example.org.
Internal Number: 00502
CalOptima is a county organized health system that administers publicly funded health care coverage for low-income children, adults, seniors and people with disabilities in Orange County, California. CalOptima’s mission is to provide members with access to quality health care services delivered in a cost-effective and compassionate manner. With $3.4 billion in annual revenue, CalOptima serves nearly 800,000 members, delivering services through 14 health networks. For the past three years, CalOptima has been rated the top quality Medi-Cal plan in California, according to the National Committee for Quality Assurance (NCQA) Medicaid Health Insurance Plan Ratings 2017–2018.