Utilization Management Director jobs in Los Angeles, CA

KP Recruiting Group is a consulting firm that provides leadership and exceptional talent to some of the world’s leading companies. Headquartered in the Midwest, KP Recruiting Group has successfully completed countless engagements in the United States, Europe and Latin America. We represent clients in all industries and all sizes. Our mission is to provide exceptional client and candidate experiences in order to get the best possible results. On behalf of our client, we are excited to present the following confidential role. We look forward to hearing from you and discussing the opportunity!

The Role:

• PROGRAM ACCOUNTABILITIES:
  • Lead the quality and utilization management programs for all LOBs. This includes unique relationships held whereby quality and utilization is a delegated function to other delegated entities
    
  • Assure that policies and operating procedures are comprehensive, implemented and reviewed annually
    
  • Analyze and interpret data, assessing impact on care or service. Develop potential interventions and cost/benefit of such interventions. Prepare and present periodic reports on specific areas of health services utilization as directed. Report performance, both activity volume and outcome, on a monthly and year-to-date basis, assessing for improvement opportunities
    
  • Prepare and present evidence of quality and utilization compliance for payer and regulatory audits and accreditation surveys
    
  • Evaluate components of Clinical Programs Management; i.e. utilization management and quality management as appropriate to area of responsibility at least annually and assess for improvement opportunities
    
  • Assist in external contracting for delegated services 
    
  • Research potential quality of care issues, assessing for system problems as well as individual, case specific issues
    
  • Responsible for oversight of delegated quality programs
    
  • Assist in the development, implementation, and maintenance of the provider reporting, which incorporates utilization, quality, and credentialing data. Collaborate with the credentialing and quality committees to ensure that provider performance monitoring is effectively handled
    
  • Oversee the quality of care complaint handling process ensuring that it is timely and compliant with external requirements
    
  • Develop action plans for health plan quality measurement programs, such as CMS 5 Star, NCQA commercial ratings, Marketplace Quality Rating System, and Health Share incentive measures
    
• DEPARTMENT MANAGEMENT AND HUMAN RESOURCES FUNCTIONS:
  • Management of staff, which includes goal setting, hiring and terminating, training, performance evaluations, the development of corrective action plans, and monitoring for improvement
    
  • Identify training needs and provide for the development and continuing education of professional staff to ensure competency
    
  • Act as a mentor and provide consultation to staff in quality and utilization management
    
• ACCREDITATION AND REGULATORY REQUIREMENTS:
  • Assure that applicable regulatory and accrediting requirements are met in a timely and professional manner. Prepare fully for all regulatory and accrediting agency audits and reviews
    
  • Develop and monitor corrective action plans and project action plans, reporting to management and committees as appropriate
    
  • Identify and implement tools that assure compliance with DMHC, CMS,, NCQA and other regulatory and accrediting agencies
    

Requirements

Benefits

Our client offers a comprehensive benefits package including:

401k Matching

Family and Individual Insurance Packages (Health, Life, Dental, and Vision)

Paid Time Off & Paid Holidays

Long & Short-Term Disability

Identity Theft Plans

Retirement & Pension Plans

Employee Assistance Program

Employee Referral Program

Tuition Reimbursement Programs

Advancement & Professional Growth opportunities 

Parental Leave

& More