Supervisor, Health Plan Clinical Operations, RN
About The Position
Supervises the overall operations of the Health Plan Clinical Operations. The ideal candidate will have experience working within a commercial health plan environment, preferably in California, with a strong understanding of DMHC (Department of Managed Health Care) and NCQA (National Committee for Quality Assurance) regulatory and accreditation requirements. Experience in Utilization Management, including medical necessity reviews, authorization processes, and coordination with providers and members, is highly desirable. Candidates should also have experience developing, reviewing, and maintaining health plan policies and medical policies, including the ability to interpret regulatory and legislative requirements and translate them into operationally sound policies and procedures. The successful candidate will possess a strong understanding of managed care operations, regulatory compliance, quality standards, and the application of health plan policies to support timely, appropriate, and member-centered care.
Requirements
- Bachelor's degree in Nursing or evidence of enrollment in BSN program with completion within 24 months OR Master's degree in Nursing, Case Management OR Bachelor's in a related field
- RN-Registered Nurse of California
- 5 years of recent relevant experience.
- Knowledge of ACMA, CMSA, and NASW Standards of Practice.
- Knowledge of available health care and community resources
- A broad knowledge base of health care delivery and case management within a managed care environment.
- Comprehensive knowledge of laws, regulations and professional standards affecting case management practice in an integrated delivery system: including but not limited to: CMS, Title 22, CHA Consent Manual, CDPH and TJC.
- Verbal and written communication skills.
- Demonstrated ability to develop and manage complex projects.
- Working knowledge of InterQual criteria.
- Working knowledge of MIDAS and experience with an E.H.R.
- Ability to promote teamwork and to effectively function in teams, both as a leader and as a team member.
- Ability to interact effectively with key internal and external constituents using collaboration, negotiation and analytical problem resolution skills.
- Effective human relations and interpersonal skills necessary to lead the efforts of diverse health professionals to meet program objectives.
- Ability to work effectively in a fast-paced environment, directing services at multiple locations.
- Analytical and mathematical skills.
- PC skills, word processing, spreadsheets and managed care software programs.
- Adheres to Sutter Health policies and procedures and supports Sutter Health philosophies and initiatives.
Nice To Haves
- Experience working within a commercial health plan environment, preferably in California.
- Strong understanding of DMHC and NCQA regulatory and accreditation requirements.
- Experience in Utilization Management, including medical necessity reviews, authorization processes, and coordination with providers and members.
- Demonstrated ability to implement continuous quality improvement processes and techniques, including benchmarking and outcomes measurements.
Responsibilities
- Supervises the overall operations of the Health Plan Clinical Operations.
- Develops, reviews, and maintains health plan policies and medical policies.
- Interprets regulatory and legislative requirements and translates them into operationally sound policies and procedures.
- Supports timely, appropriate, and member-centered care.
- Participates as a member of the utilization Management Committee (UMC).
Benefits
- Comprehensive benefits package
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Manager
