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At Hill Physicians Medical Group, we’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.
Join Our Team!
Hill Physicians has much to offer prospective employees. We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and have been recognized as one of the “Healthiest Places to Work in the Bay Area.” When you join our team, you’re making a great choice for your professional career and your personal satisfaction.
DE&I Statement:
At PriMed, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.
We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!
Job Description:
To perform and oversee all quality internal monitoring for the prior authorization department. The Utilization Management Quality Management (UMQM) Nurse position is meant to ensure the quality of the work of the individuals in the Prior Authorization Department. The UMQM Nurse shall also participate in Utilization Management related activities with the Appeals and Grievance Department as well as the Compliance Department to assure that the quality compliance is being met for NCQA, state and federal regulatory requirements. This position will work with Health plans as directed to ensure quality is met for our delegation oversight. This position reports to the Director of Utilization Management.
Key Tasks and Responsibilities:
- Participates in health plan audits and represents Hill Physicians Medical Group (HPMG) at the audits for the Prior Authorization Department. Acts as the liaison for Prior Authorization regulatory and compliance issues.
- Monitors the UM standards compatible with health plans, NCQA, state and federal regulatory requirements, and health plan delegation changes by conducting established monitoring audits to both clinical and non-clinical authorization requests.
- Updates, suggests or develops relevant HPMG guidelines as they relate to audit trends and health plan changes.
- Works with the UM Training Manager to implement new and or revised guidelines or procedures when appropriate as it relates to above requirements.
- Participates in the testing of system changes, upgrades, service packs, etc. as needed.
- Assists in the daily requests for Grievance and Appeals.
- Maintains compliance with performance standards.
- Identifies Grievance and Appeals trends and implements process improvements as needed.
- Tracks and reports results of monitoring per the policies of the department.
- Conducts Root Cause Analysis (RCA) in conjunction with Compliance.
- Recommends program improvements based on RCA’s or corrections as identified.
Skills and Experience:
- Active CA RN nursing license, CA driver’s license.
- Graduation from an accredited school of nursing. BSN preferred.
- Critical thinking skills and analytical experience in utilization and/or Quality Management.
- Proficient in Word, Excel, and Outlook.
- Preferred: Knowledge of NCQA, CMS, DMHC, DHCS, California Health and Safety Codes, and Milliman, Care Guidelines.
- Preferred: Teaching and training experience in a health care setting.
Salary Range
$82,800 - $115,100
Additional Information
Hill Physicians is an Equal Opportunity Employer
