Children's Physicians Medical Group (CPMG) is a pediatric-only Independent Physicians Association (IPA), associated with Rady Children's Hospital - San Diego. We’re proud to provide San Diego County and Southern Riverside the only integrated pediatric network of primary care, specialty care and hospital services, as a part of Rady Children’s Health Network.
CPMG is currently seeking qualified candidates for the position of Utilization Management Operations Manager. The candidate oversees and coordinates operations in the UM Coordinators team and ensures consistent quality service in both authorization processing and in completion of phone calls.
The essential duties of this position will be:
- Management of UM Coordinator staff, including HR issues, performance management, coaching, and mentoring.
- Continuously monitors departmental needs and implements necessary changes regarding adequate staffing, education, training opportunities, and team building.
- Conducts weekly team meetings, creating an agenda, topics for discussion, and the focus of the meeting.
- Administration of departmental software systems – EZ-Cap, RightFax, Qlik Dashboards, SSRS Reporting – for user access, troubleshooting, training, etc.
- Create & Analyze employee productivity statistical reports; identify trends, problems, and any resolution needed.
- Maintains or revises current, or creates new, policies, procedures, and training tools regarding Department activities in compliance with new and updated regulations to accurately reflect CPMG processes.
- Handles escalated member or provider issues, which includes reviewing, researching, and collecting information from the appropriate entity (claims, contracting, medical director, etc.)
- Works collaboratively with the UM Clinical team, the Director, and clinical leadership to identify and implement process improvement initiatives.
- Communicates with key health plan contacts to ensure resolution of claims, benefits, and authorization disputes, as well as problem solving for other identified issues.
- Maintain collaborative relationships with Provider Relations, Claims, UM Clinical, and Contracting Departments to ensure resolution of identified issues or concerns.
- Management of the inbound call center for members and providers, including regular monitoring for quality assurance purposes.
- Management of Electronic Utilization Management (UM) processes.
- Management of Rady Children’s MSO Customer Service processes.
EDUCATION AND EXPERIENCE
High School Diploma with a minimum of 3 years supervisory experience in managed care, at a health plan or medical group level. Bachelor’s Degree Preferred. Knowledge of health plan processes, benefits, authorizations, claims, and ICD-10/CPT coding required. Advanced computer skills, specifically Excel, EZ Cap, Word, Outlook, Internet/Web searching, Epic, Calabrio, and ACD phone systems. Statistical analysis experience required.
The reasonably expected starting salary wage range for this position is $80,000-$87,000 yearly depending on qualifications including education and relevant experience.
We conduct pre-employment background checks and drug screens as conditions of hire. Job offer is contingent on successful participation in Children’s Physician Medical Group (CPMG) COVID-19 Vaccination Policy. For the safety and well-being of our pediatric community, many of whom are not eligible for their COVID-19 vaccine yet, CPMG requires that all staff be vaccinated against the COVID-19 virus. Job offer is contingent on successful participation in Children’s Physician Medical Group (CPMG) COVID-19 Vaccination Policy.
For consideration please email resume and cover letter including salary requirements. Children’s Physician Medical Group offers the full scope of benefits, a great compensation package and opportunities for professional growth. An Equal Opportunity Employer. For more information please visit our website www.cpmgsandiego.com. This position is located in San Diego, CA
Job Type: Full-time
Pay: $80,000.00 - $87,000.00 per year
- 401(k) matching
- Dental insurance
- Employee assistance program
- Flexible spending account
- Health insurance
- Life insurance
- Paid time off
- Retirement plan
- Vision insurance
- 8 hour shift
- Monday to Friday
Work Location: In person