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Children’s Physicians Medical Group (CPMG) is a pediatric-only Independent Physicians Association (IPA), affiliated with Rady Children’s Hospital – San Diego and Rady Children’s Specialists of San Diego.  These providers have formed an Integrated Delivery System (IDS) known as Rady Children’s Health Network (RCHN), which includes 200 primary care pediatricians and over 450 pediatric specialists. Currently, over 78,000 children are enrolled in CPMG through nine managed care Health Plan contracts and three Medi-Cal contracts. Additionally, CPMG and its network partners provide MSO services to 400,000 other patients and their providers in San Diego, Southern Riverside, and Orange County.

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.

• 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.