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DIR, UTILIZATION MANAGEMENT (RN) - SCRIPPS HEALTH PLANS in San Diego, CA at Scripps Corporate Admin Services

Date Posted: 5/1/2019

Job Snapshot

Job Description

Change Lives, Starting with Yours 
At Scripps Health, you will experience the pride, support, respect that has been repeatedly recognized as one of the nation’s Top 100 Places to work.
You’ll be surrounded by people committed to making a difference in the lives of their patients and their teammates.  So if you’re open to change, go ahead and unlock your potential.
For the second year in a row, U.S. News & World Report has rated Scripps Health as No. 1 in San Diego, No. 6 in California and among the best in the nation in multiple specialties. 
Truven Health Analytics named Scripps Health among the top five large health systems in the nation. Scripps was the only California health care system on the Truven Top 15 Health Systems list this year. This is the fifth time Scripps has received the honor.
At Scripps Health, you can feel the pride of meaningful work and confidence that you matter in an organization that makes a real difference in the lives of our patients and community.  You will be surrounded by a highly engaged and talented team of individuals committed to developing innovative solutions on the leading edge of healthcare.
As Director, Utilization Review, you will be responsible for the development, implementation and maintenance of clinical and operation performance of medical and utilization management programs and work plans across all the Managed Care Health plan contracts. You will develop and implement ongoing data reporting used to drive decision making on operational functions related to access to care and outcome reporting.
Play an integral role in promoting member safety through the review of high risk services, inpatient and discharge planning to all members. Be responsible for the oversight and delivery of all reporting required for delegated functions as well as evaluation of the data and leading implementations for delivery of care in the safest most effective manner. Assume the lead for developing and delivery of a complex case management program that integrates care between providers and members
Additionally, you will be responsible for development and outcomes of a complex and supportive case management program that meets Medicare Medicaid and Commercial requirements that promotes member health in their own environment. Be responsible for attaining and maintaining National Committee for Quality Assurance NCQA accreditation.
This is a Full Time, Director position located in Rancho Bernardo.

Job Requirements

Required Education/Experience/Specialized Skills:
  • Five years clinical experience in a variety of clinical settings.
  • Five years in a management or leadership role with a proven ability to balance multiple tasks and priorities.
  • Ability to supervise a department comprised on staff functioning at a variety of professional levels and problem solve.
  • Experience in the development and implementation of Medical Management programs and processes with a managed care company.
  • Experience with Case Management for complex cases including Medicare and Medicaid rules and requirements.
  • Experience in developing a Case Management model that integrates care across systems.
Required Certification/Registration:
  • Valid California Registered Nursing license.
Preferred Education/Experience/Specialized Skills/Certification:
  • BSN preferred.
  • Training in National Committee for Quality Assurance (NCQA) measures for health plan.
  • Expertise in managed care guidelines (Knox-Keene) Medicare and Medicaid regulations.
  • Experience with MCG Medicare National Clinical and Local Clinical Guidelines pharmacy guidelines and administering guidelines to qualified healthcare professionals.
  • Strong organizational skills and ability to continuously evaluate workflows and efficiencies.
  • Experience with system implementations.
Clinical Nurse leader
Scripps Health is repeatedly named on the Fortune Magazine’s 100 Best Companies to work for, only San Diego-based Company and Becker’s Healthcare Top Hospitals. Scripps Health offers a robust Total Rewards Program designed to compensate and motivate you throughout your career. Scripps Health Total Rewards Program includes a broad range of plans and programs including market competitive pay and performance incentives, health and wellness benefits, financial wellness benefits, work-life resources, learning and development opportunities, and rewards and recognition. Unlock your potential with Scripps Health today.

Scripps Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age, marital status, status as a protected veteran, among other things, or status as a qualified individual with disability.