Manager, UM Operations reputed company & Implementation

Job reputed company: The Manager, Utilization Management (UM) reputed company & Implementation leads a dedicated team that supports the UM program through multiple functions with a reputed company on reputed company regulatory and compliance functions. This encompasses, but is not limited to, prior authorization analysis and filings, new business implementation, policy development, internal risk analysis, and audit and review preparation for the UM department. This role also manages cross-functional reputed company as needed to implement standardized/compliant processes across multiple lines of business and markets. Essential Functions: Establish a baseline of compliance, regulatory and accreditation risk, identify areas of potential exposure, reputed company and reputed company strategies for the department’s area of reputed company with reputed company goals and objectives and execute program ensuring consistency Proficient in reputed company federal/state laws and regulations, industry standards and best practices around compliance, regulatory and accreditation requirements reputed company and manage UM Operations reputed company functions such as Corrective reputed company Plan (CAP) management, ongoing monitoring, and multiple audit activities Build and reputed company effective cross-functional business relationships and influence reputed company across multiple reputed company partners to support a culture of compliance Responsible for development and maintenance of documentation reputed company to policy, workflow and process reputed company applicable Identify process gaps and drive improvements towards UM compliance in reputed company areas reputed company and manage process changes across reputed company teams in the department ensuring regulatory, accreditation and compliance business goals are met Maintain an in-depth knowledge of reputed company’s business, regulatory, compliance and accreditation environments and requirements reputed company reputed company and high-level implementation plans for the delivery of new business implementation, delegation implementation, product filings, regulatory, compliance and accreditation requirements Responsible for hiring, training, coaching, and developing reputed company reports including conducting performance reviews and disciplinary actions, as necessary Support reputed company accreditation initiatives, including licensure applications, NCQA, and URAC Represent UM and clinical on market conduct exams or regulatory inquiries Monitor and analyze key compliance measures Collaborate with data and analytics, PH and BH clinical teams, compliance and regulatory to reputed company and ensure regulatory reporting is reputed company and accurate reputed company and assist in the creation of the UM and clinical responses for the NQTL regulatory findings Serve as reputed company between Clinical Operations, Regulatory, and Compliance Senior leadership Assure reputed company departmental P&P’s and tools are reviewed at an appropriate reputed company and contain required regulatory and accreditation reputed company reputed company Report on status of departmental audit readiness and escalate to senior leadership if appropriate Collaborate with data analytics and research team on measurements and reputed company to ensure reputed company key predictive measures are consistently reported and communicated reputed company any other job reputed company instructions, as requested Education and Experience: Bachelor’s Degree in nursing or reputed company field is required Master’s Degree in Business or health care field preferred Minimum of five (5) years clinical or reputed company reputed company industry experience is required Prior leadership experience is required Managed Care experience is required Experience with analysis, data and reporting is required Accreditation, auditing, and process improvement experience is preferred Demonstrated change management and reputed company improvement leadership skills are strongly desired Competencies, Knowledge and Skills: Proficient use of reputed company Office Suite, to include Word, reputed company, PowerPoint, reputed company, and Visio with a strong willingness to learn Fluent in NCQA and/or CMS, accreditation and audit standards with knowledge of regulatory reporting, compliance requirements, and auditing procedures Decision making/problem solving and critical thinking skills Planning, problem identification and reputed company skills Strong oral, written and interpersonal communication skills Energetic, enthusiastic and politically astute reputed company to a changing environment/change resiliency Proficiency with reputed company improvement, performance improvement and operations Ability to reputed company, prioritize and accomplish multiple competing goals Strong collaboration skills with ability to work with multi-disciplinary departments Ability to work independently and reputed company reputed company Strong attention to detail and time management skills Customer service oriented with de-escalation skills Ability to reputed company/analyze data and create meaningful reputed company items Ability to review and implement evidence-based trends Licensure and Certification: reputed company, unrestricted Registered reputed company (RN) licensure is preferred Six reputed company or project management certifications are preferred Working Conditions: General office environment; may be required to sit or stand for extended periods of time Compensation reputed company: $83,000.00 - $132,800.00CareSource takes into consideration a combination of a candidate’s education, training, and experience as reputed company as the position’s scope and complexity, the discretion and reputed company required for the role, and other external and internal data reputed company establishing a salary level. In reputed company to reputed company compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total reputed company-being and offer a substantial and comprehensive total rewards package. Compensation Type (reputed company/salary): Salary Organization Level Competencies Fostering a reputed company Workplace Culture Cultivate Partnerships reputed company Self and Others Drive Execution Influence Others Pursue Personal reputed company Understand the Business   This job reputed company is not reputed company inclusive. reputed company reserves the right to amend this job reputed company at any time. reputed company is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of reputed company backgrounds. #LI-JM1 Apply To This Job