Position Title: Director, Medical Management
Department: Medical Management
Level: Senior Team
Reports To: Chief Executive Officer
Position's Access to Private Health Information (PHI): Position requires “read and write” access to member authorizations, “read only” access to claims and eligibility.
Job Classification: Exempt
Job Type: Full Time
Shift Days & Times: Monday - Thursday | 6:30 AM - 5:00 PM PST
Pay Rate: $63.49 - $83.18/hr. Salary is based on qualifications and experience.
Position Summary:
Ensure quality health care services are provided to our clients and members, providing oversight to the quality management, utilization management and credentialing functions of the organization.
Essential Job Functions:
· Develop, implement and update medical management programs in the areas of utilization management, case management, quality improvement, credentialing and member/provider appeals to remain current with health care trends and legislative requirements.
· Direct responsibility for the department’s operations for quality management including credentialing, member and provider appeals, utilization management including inpatient, outpatient and high risk case management and maintaining positive relationships with the Medical Directors, Health Plan Representatives, Senior Team and Clients.
· Responsible for maintaining Client’s delegated status for utilization management and credentialing with all contracted health plans. Review and assist in the negotiations of health plan delegation agreements on an annual basis.
· Develop, review and revise departmental policies and procedures at least annually to ensure current legislative and regulatory compliance.
· Ensure staff recruitment and selection process and performance evaluations are completed in a fair and consistent manner.
· Supports vision of the Senior Team. Actively participates in developing solutions to strategic issues.
· Works collaboratively with other Senior Team members and SCPMCS department managers for high quality MSO services.
______________________________________________________________________
Position Qualifications and Requirements:
Experience/Specialized Skills:
· Three to five years experience at a senior level in medical management in a managed care, health plan, or medical group setting.
Education/Course(s)/Training:
· Bachelor of Science Degree, Master’s Level preferred.
Licensure/Certification: Current unrestricted California Registered Nurse licensure. Reliable transportation, valid California Driver’s license and proof of insurance.
Location: Mira Mesa, San Diego
Date Posted: 06.10.2024
To apply for this position, complete the employment application following the link below and submit it to jobs@scpmcs.org
Job Type: Full-time
Pay: $63.49 - $83.18 per hour
Expected hours: 40 per week
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Employee assistance program
- Health insurance
- Life insurance
- Paid time off
- Tuition reimbursement
- Vision insurance
Application Question(s):
- How many years of Managed Care experience do you have?
- What are your salary expectations?
Education:
Experience:
- Senior level Medical Management: 3 years (Required)
License/Certification:
- California RN License (Required)
Ability to Commute:
- San Diego, CA 92121 (Required)
Ability to Relocate:
- San Diego, CA 92121: Relocate before starting work (Required)
Work Location: Hybrid remote in San Diego, CA 92121