Job Description

Medix is currently hiring for an Outpatient UM Clinical Manager for a Health Plan Organization in Sherman Oaks California. This position is a hybrid (2 days onsite 3 days remote). Standard Business Hours Mon-Fri, PST

Job Description

Reporting to the VP of Medical Affairs, the Outpatient UM Clinical Manager is responsible for the daily operations and oversight of the Outpatient UM Clinical Team. This role ensures that the Clinical team functions in accordance with internal policies and procedures and meets health plan contractual requirements and regulatory standards.

Duties and Responsibilities

• Manages areas including organizing and executing all activities, staffing, performance improvement in the delivery of clinical services
• Consults and collaborates with other managers, physicians, administration, Health Plans and Clients
• Acts as liaison between providers, Health Plans, and Hospital Clients
• Communicates with physicians at regular intervals and develops an effective working relationship. Assist physicians in maintaining appropriate cost, case, and desired patient outcome
• Approves and reviews HP CAPs; Mitigate key risk areas identified in HP audits. Understands strategy and how it applies to his/her department. Maintains a high level of understanding of external factors affecting clients' market
• Provides oversight of Paid time off (PTO), Overtime (OT) & Compliance. Plans offsite team events and nominates Teammates (TM’s) for Core Value Awards. Conducts regular one-on-one with direct Supervisors
• Oversees the clinicians' review process to ensure that it’s in accordance with industry standards, health plan contracts and regulatory requirements
• Monitors the utilization of outpatient services and ensures that patients receive high-quality care
• Reviews outpatient services to identify trends of over- and under-utilization and reports issues to VP Medical Affairs, as appropriate
• Oversees all UM Committee functions and ensures that documentation is per NCQA and health plan standards
• Oversees the investigation and resolution of grievances identified through the QM Department and/or the health plans

3-5 Must Have Skills/Qualifications

• Possession of a valid RN/LVN license issued by the State of California required.
• 5+ years’ experience in utilization and/or case management, preferably in a medical group or IPA setting
• 2+ years supervisory experience
• Knowledge of current and new regulations on federal, state, and local levels, as well as practice guidelines and standards of practice

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