Manager Utilization and Care Management Sharp Healthcare - San Diego, CA - Full-time / Part-time

Location

This position is located in Kearny Mesa, CA (San Diego County)

Hours

8-hour day shift, 8:00 am – 5:00 pm; weekends as needed

Full-time (1.0 FTE) exempt position

Required Skills and Qualifications

• Graduate of NLN accredited school of nursing
• Current, unencumbered California RN license
• Bachelors of Science in Nursing
• Minimum of five (5) years of Utilization/Quality/Case Management experience in a Managed Care setting
• Three (3) years managerial experience and knowledge of current standards of practice and available health resources in the community

Preferred Skills and Qualifications

• Master’s degree in a healthcare, business or leadership discipline
• Health Plan and Medical Group experience
• Experience working with California state exchange product
• Experience working with the Medicare Advantage product
• Participation in a Utilization Management, Case Management or Quality Improvement organization
• Ability to work multiple projects and efforts simultaneously
• Excellent verbal and written communication and presentation skills
• Strong ability to work well with staff with various educational and professional skill backgrounds to achieve common goals and promote collaboration
• Demonstrated leadership and mentoring skills
• Thorough computer knowledge, including on-line database and personal computer skills
• Knowledge of wide variety of local and national resources for use in Utilization Management (UM) process
• Strong organizational skills with ability to work well under pressure with conflicting priorities
• Ability to analyze and interpret data and prepare concise, accurate reports
• Ability to initiate studies, gather statistical data and trend outcomes
• Excellent written and verbal communication skills
• Strong organizational, analytical and problem solving skills
• Ability to develop and implement projects

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability.

Summary

Under the direction of the direction of the Director of Population Health and Medical Management and in collaboration with the Chief Medical Officer (CMO), Medical Director and other Health Services Managers/Directors, this position is accountable and provides leadership and management for promoting effective Utilization management and Care Management programs (case and disease management).

This position is responsible for the implementation, improvement practices and maintenance of effective Utilization Management (UM), Complex Case Management (CCM) and Disease Management (DM) programs. These programs encompass a “Patient-Centered” Care Management approach that includes; prospective, retrospective and concurrent utilization management for both physical and behavioral health, in addition to inpatient care management, care coordination, case management, and quality management. This position is responsible for managing complex projects, problem solving and researching data to facilitate business activities for the development of and/or enhancements to current programs in order to improve the management provided to the membership. The Manager will provide leadership and support for delegation oversight.

The Manager provides direct management of the UM and CM team. Responsibilities include modeling effective leadership and mentoring skills for the department clinical and non-clinical staff, promoting staff cevelopment and providing the necessary mentoring skills using the concepts and tools supporting the “Sharp Experience”.

The manager ensures the department adheres to and maintains regulatory and legislative compliance from CMS, NCQA, DMHC, and other regulatory bodies related to UM, CCM and DM.

Sharp Health Plan is a locally based, not-for-profit health plan that has been serving San Diegans for over 25 years. With more than 145,000 members, Sharp Health Plan offers San Diegans access to high quality and affordable health insurance through its individual and family plans, commercial group plans and Medicare plans. Sharp Health Plan continues to be recognized nationally and locally for its award-winning healthcare for San Diegans of all ages.

In 2020, Sharp Health Plan earned a 5-star rating – the highest possible – for patient experience in the annual Health Care Quality Report Card from California’s Office of the Patient Advocate (OPA). It was the only health plan in California to achieve a 5-star rating for patient experience. Sharp Health Plan also earned top marks, 4 out of 5 stars, for quality of medical care.

Sharp Health Plan was named to the 2021 U.S. News and World Report list of Best Insurance Companies for Medicare Advantage in California. Sharp Health Plan earned an overall rating of 4.5 out of 5 stars by Medicare for the second year in a row. It also achieved a 5-star score for ratings of the health plan, health care quality, drug plan and care coordination. This places Sharp Health Plan within the top 100 Medicare Advantage plans in the nation.