Principal of Medical Management (Utilization Management) (Director Level)
The Principal of Medical Management is responsible for planning, organizing, and directing Hoag Clinic operations of all areas related to Utilization Management, Quality Management, Medical Group Referral Services, and Pharmacy Services. The Principal coordinates duties with appropriate personnel to meet operational program needs that ensure compliance with state, federal, and health plan requirements; Medicare guidelines; and NCQA standards. Principal is responsible for implementing operational policies and procedures; integrating and updating current clinical practice guidelines. They will be responsible for oversight and/or performance of employee counseling, appraisals, training and development. The success of this position requires the ability to foster communication and teamwork between physicians, clinic staff, medical management staff, corporate departments, vendors, and senior leadership. The Principal will assist senior leadership with long-term planning priorities to maintain operations assuring activities are appropriately integrated into Organizations strategic direction.
Job Knowledge, Skills, and Competencies
Change Management – Adapts to changes in the environment on a personal and workload basis. Facilitates constructive and positive change in a team, unit, or other work group, including in areas of innovation and new processes, technology and strategy.
Conflict Resolution – Manages conflict, disagreement and discord among and between staff and work units, while recognizing and addressing sensitivities and stakeholder needs.
Critical Thinking – Demonstrates the ability to actively and skillfully conceptualize, apply, analyze, synthesize and/or evaluate information gathered from, or generated by, observation, experience, reflection, reasoning, or communication.
Decision Making – Knows when and what decisions should be made in a fast-paced, rapidly changing environment, and is able to act upon and put those decisions in place.
Diversity – Demonstrates ability to work with a diverse group of people in a manner that enables them to reach their full potential, in pursuit of organizational objectives.
Technology & Equipment Skills – Maintains knowledge of technology, tools, equipment and other devices in work area. Demonstrates competence in technology skills required for the role, as well as ability to learn and master new skills. For clinical position this includes equipment and devices pertinent to treatment, procedures and practice.
Interpersonal Skills – Listens to and understands what others are saying. Establishes effective working relationships with others, contributing to a climate of mutual respect and cooperation. Uses language to the situation. Demonstrates sensitivity and tact, understanding own effect on the motivation, attitudes and actions of others. Makes favorable first impressions.
Job Knowledge – Demonstrates full knowledge and understanding of concepts and procedures needed to be successful in the role, including knowledge of applicable department, organization and external rules and regulations impacting day to day processes. For clinical positions, this includes clinical procedures required by department and unit, as demonstrated by unit-based competency testing.
Operational Management – Effectively manages people, resources, deliverables, budgets, general administration and other components of day-to-day management of functional unit or department.
Oral/Written Communication – Ability to speak and write effectively, demonstrates fundamental command of language, communicates well using all mediums.
Travel – Position may require local travel between various Organization locations
Education and Experience
- Bachelor of Science degree, in Nursing, Management, Business Administration or related field.
- Five to seven years’ experience in managed care and/or disease/medical management with a minimum of five years at the management level in managed care organization.
- Five years work experience applying evidence-based criteria (i.e.: Milliman, Interqual); Health plan medical policy / clinical coverage guidelines.
- Five years work experience implementing requirements set forth by regulatory agencies. This includes but is not limited to: contracted Health Plans, Centers for Medicare and Medicaid (CMS), NCQA (National Committee for Quality Assurance) SNP (Special Needs Plans); DMHC (Department of Managed Health Care); and ICE (Industry Collaborative Effort).
Preferred:
- Master degree of Science degree, in Nursing, Management, Business Administration or related field.
- Familiarity with Epic Healthy Planet module
- Experience working in an integrated healthcare delivery system
Licenses
- Current license as a Registered Nurse (RN) in the state of California required
Certifications
Source: Indeed.com
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