Medical Management Services Manager - Rn Required (On-Site)

POSITION SUMMARY:
This position is responsible for oversight and management of CalViva Health clinical, service, and quality improvement programs and initiatives to ensure compliance with applicable accreditation, state and federal requirements for the Medi-Cal Managed Care business. This position serves as back up to the Director of Medical Management in their absence. Under the direction of the Director of Medical Management and the Chief Medical Officer, the Medical Management Manager will work collaboratively with CalViva Health’s (CVH) staff and its contracted Plan Administrator to monitor and report on clinical, service, and quality related data and issues and implement improvements through policy and process enhancements.

ESSENTIAL DUTIES & RESPONSIBILITIES:

• Manage and oversee the review and revision of Medical Management policies and procedures to ensure they address current and new applicable statutes and/or regulations.
• Manage directly reporting Medical Management staff and oversee department activities.
• Manage the review, preparation, and submission of documents and policies for the DHCS/DMHC Medical Audits.
• Lead, coordinate and monitor the delegation oversight audits of the Plan Administrator that Medical Management conducts. Lead the delegation audit process, develop reports regarding audits, and analyze, track and trend audit findings.
• Coordinate preparation for the Appeals and Grievances Work Group including draft agenda & minutes, report gathering and follow up.
• Prepare and review required CalViva reports, program documents and workplans as requested.
• Support and participate in Quality Improvement projects and teams including meeting agendas, tracking logs and regulatory submissions.
• Attend CVH Quality Improvement/Utilization Management Committee, QI Work Group, Monthly Case Management, Utilization Management, HEDIS, and other routine and ad hoc meetings.
• Interact with HNCS staff as necessary in fulfilling duties of this job description.
• Function as back up for the Appeal & Grievance file transfer process including auditing the cases to ensure files are complete and ready for regulatory audits.
• Other duties as assigned by the Director.

MINIMUM QUALIFICATIONS:
EDUCATION:

• Healthcare related Bachelor’s degree or completion of an accredited RN program required.
• Master’s degree –MPH or MPA-- is highly desirable.
• Certification in Healthcare Quality (CPHQ) desirable.

LICENSES:

• RN license as appropriate
• Current driver’s license

EXPERIENCE:

• Five years progressive experience in Healthcare Quality Improvement and/or Project Management.
• Previous managerial experience preferred.
• Minimum of two years’ experience in healthcare service environment.

KNOWLEDGE, SKILLS & ABILITIES:

• Strong knowledge of healthcare federal, state and NCQA standards and regulations.
• Knowledge of Managed Care Operations.
• Ability to effectively develop, analyze, interpret, and communicate healthcare data reports and processes.
• Effective verbal and written communication skills.
• Strong organizational, analytical and problem-solving skills.
• Must be proficient in Microsoft Office: Word, Excel, PowerPoint, Access and Outlook.
• Possess the ability to effectively organize and prioritize projects and multi-task.
• Ability to take initiative and work independently.
• Team player who can establish and maintain effective working relationships at all organization levels.
• Exercise a high degree of maturity, integrity, loyalty, initiative, creativity and sound judgment.

Physical Requirements

• Constant and close visual work at desk or computer.
• Extensive typing
• Constant sitting and working at desk.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent walking and standing.
• Frequent lifting of folders, files, binders and other objects weighing between 0 and 30 lb.
• Must have reliable transportation, may be required to travel between Kings, Madera and Fresno counties as well as between offices for meetings.

Note: The information in this position description indicates the general nature and level of work performed by employees within this classification. It is not designed to be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.