The ideal candidate has experience performing review of long term care and/or skilled nursing facility services.
ABOUT US: Central California Alliance for Health (the Alliance) is an award-winning regional non-profit Medi-Cal health plan. The Alliance began operating in 1996 and uses the State’s County Organized Health System (COHS) model of Medi-Cal managed care. Our vision is to be a recognized leader in creating local health care solution.
We currently serve over 350,000 members in three counties (Santa Cruz, Monterey and Merced) in Central California. We are a group of over 500 dedicated individuals driven by our mission of providing accessible, quality health care that is guided by local innovation. We are value-based, guided by the following:
• Culture: We strive for a respectful, diverse, professional and fun workplace. • Customer Service: Our customers’ satisfaction is our highest priority. • Excellence: We value and continuously improve quality in our services. • Innovation: We leverage local talent to create solutions. • Integrity: We tell the truth and do what we say we will do. • Partnership: We collaborate with others for strong solutions. • Stewardship: We manage responsibly, and earn the trust of partners and regulators.
We approach health care with innovative methods, and include care management of high utilizers, and social determinants of health in our strategic planning. We strive to develop a regional health care system that delivers quality, high value health care, and we engage actively with our community partners, agencies and stakeholders to share this responsibility.
RESPONSIBILITIES: Supervises the daily activities of the Utilization Management (UM) Concurrent Review staff, coordinates and implements effective and efficient UM processes which include UM Concurrent Review and SNF Programs, performs duties as a UM Concurrent Review Nurse, as needed, assists UM Manager - Concurrent Review and department Director in preparation for audits and other regulatory activities, and performs other duties as assigned.
YOU WILL BRING: • Knowledge of: - Medi-Cal and related policy and Title 22 regulations - Concepts pertaining to prepaid health care - Utilization Management, and/or Case Management principles and practices • Ability to: - Effectively use Microsoft Office Word, Excel and Outlook - Evaluate medical records and other health care data - Exercise good judgment and tact in relating to contracting health care providers and beneficiaries - Give clear direction and sequence information verbally, so others can follow and understand • Thorough knowledge of and proficiency in applying effective people management skills including leading team building, facilitating efficient and effective meetings programs and/or projects, problem solving, negotiating and influencing • Experience in a managed care setting • Working knowledge of Milliman Care Guidelines in review determination process. • Education and Experience: - Current, valid and un-restricted California Registered Nurse licensure - Three (3) years of utilization management experience - One (1) year of supervisory or team leadership experience in the healthcare setting
BENEFITS: • Medical, Dental and Vision Plans • Generous Paid Time Off • 11 Paid Holidays per Year • 401(a) Retirement Plan • 457 Deferred Compensation Plan • Tuition Reimbursement • Costco Membership Reimbursement • Health and Wellness Program • Fresh Fruit Delivery • Electric Vehicle Charging Stations • And many more! (https://ccah-alliance.silkroad.com/map_images/main/SiteGen/ccahext/Content/Uploads/Unplaced_Documents/Benefits_Summary.pdf) For a complete position description and to apply online, please visit our careers website at https://ccah-alliance-openhire.silkroad.com/epostings/index.cfm?fuseaction=app.jobinfo&jobid=552&company_id=16798&version=1&source=ONLINE&jobOwner=992378&aid=1
If this sounds like an opportunity that you or someone you know may be interested in we invite you to apply! Applicants must be currently authorized to work in the United States on a full-time basis.
The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, protected veteran status, or disability status.