UTILIZATION MANAGEMENT OPERATIONS MANAGER (non-clinical)

CPMG is currently seeking qualified candidates for the position of Utilization
Management Operations Manager (non-clinical). 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.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Management of UM Coordinator (non-clinical) 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.

REQUIREMENTS

• Bachelor’s degree or a minimum of 3 years supervisory experience in managed
  care, at a health plan or medical group level.
• Knowledge of health plan processes, benefits, authorizations, claims, ICD-10/CPT
  coding.
• 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 wage range for this position is $80,000-
$87,000 depending on qualifications including education and relevant experience.

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
Children’s Physicians Medical Group offers the full scope of benefits, a great
compensation package and opportunities for professional growth. EOE. For more
information, please visit our website www.cpmgsandiego.com. This position is located in
San Diego, CA.

UTILIZATION MANAGEMENT COORDINATOR – Level 1 (non-clinical)

CPMG is currently seeking qualified candidates for the position of Utilization
Management Coordinator – Level 1 (non-clinical). This position communicates with
members, providers, and health plans through the prompt, accurate and courteous
resolution of a variety of issues.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Receives and respond to customer inquiries (telephone, written and electronic) that
  may pertain to all phases of CPMG operations including authorizations, claims
  inquiries and provider network access.
• Documents all customer contacts, including resolution or action taken to refer
  question to proper entity.
• Assists and educates member families with navigation of HMO processes.
• Data entry/processing of authorization requests, including verification of benefits,
  research of authorization history, provider notes, use of correct CPT/ICD9 codes.
• Provides referrals within the CPMG network.
• Works collaboratively with all professional entities relating to CPMG business.
• Assists colleagues as necessary on special projects with time critical deadlines.

REQUIREMENTS

• High School diploma and previous experience in the health care field, such as
  hospital, medical group, health insurance, or other Risk Bearing Organization
  (RBO). Bachelor’s Degree will be considered in lieu of experience.
• Medical Terminology, ICD-10 Codes, CPT Codes, HCPC Codes, Health plan benefits,
  or claims preferred. Computer skills a plus, specifically Excel, EZ-Cap, Word,
  Outlook, Internet/Web searching, and Epic.

The reasonably expected starting hourly wage range for this position is $20.00-$22.00
depending on qualifications including education and relevant experience.

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.
Children’s Physicians Medical Group offers the full scope of benefits, a great
compensation package and opportunities for professional growth. EOE. For more
information, please visit our website www.cpmgsandiego.com. This position is in San
Diego, CA.