Manager, Utilization Management Claims Review Job at L.A. Care Health Plan (Los Angeles)

Job Description

The Manager, Utilization Management Claims Review is responsible for overseeing the clinical and operational functions of the Claims Review team. This position provides leadership and strategic direction to ensure accurate clinical claim determinations, regulatory compliance, and adherence to established clinical policies. The Manager drives payment integrity initiatives through effective oversight of pre-payment review, retrospective review, and Provider Dispute Review (PDR) processes while ensuring regulatory timeframes and quality standards are consistently met. The Manager, Utilization Management Claims Review partners with internal departments and executive leadership to promote effective workflows, mitigate fraud, waste, and abuse (FWA), and support high-quality, cost-effective care delivery and organizational performance goals. The Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Participates and makes recommendations on the department's strategic planning and/or long-term decision-making.

Job Responsibility

Manage staff, including, but not limited to monitoring of day-to-day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others
Ensure quality standards are met by regularly reviewing claim files, clinical decisions, and Provider Dispute Review (PDR) determinations to confirm compliance with company policies, clinical guidelines, and regulatory requirements
Identify trends or errors and implement improvements to increase accuracy and consistency
Establish team goals, monitor performance metrics, and ensure productivity and quality standards are met
Support recovery efforts and corrective action plans related to inappropriate billing or utilization patterns
Oversee workflow and queue management to ensure claims and PDR requests are completed within required regulatory timeframes, including monitoring workload distribution
Ensure adequate staffing resources and prevent backlogs or compliance risks
Ensure clinical policies are applied correctly and consistently, including policies designed to prevent fraud, waste, and abuse (FWA)
Potential FWA concerns are identified and escalated in partnership with Compliance and the Special Investigations Unit (SIU)
Support audits, regulatory readiness, and cross-functional initiatives to maintain compliance with state, federal, and accreditation standards
Implement and monitor adherence to Utilization Management (UM) policies, procedures, and turnaround time requirements
Work cross-functionally with leadership to ensure claims are aligned, and well-received by internal and external stakeholders
Foster teamwork, accountability, and continuous improvement while ensuring departmental goals align with organizational priorities
Manage complex projects, engaging and updating key stakeholders, developing timelines, leading others to complete deliverables on time and ensure implementation upon approval
Responsible for reporting, budgeting, and policy implementation
Perform other duties as assigned

Requirements

Bachelor's Degree in Nursing
In lieu of degree, equivalent education and/or experience may be considered
At least 6 years of experience in Clinical Nursing
At least 3 years of experience with Medi-Cal and Medicare in a managed care environment
At least 4 years of leading staff, supervisor/management experience
Experience in performing and creating clinical documentation
Experience in regulatory compliance for a health plan
Experience leading teams, projects, initiatives, or cross-functional groups
Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement
Registered Nurse (RN) - Active, current and unrestricted California License
Strong leadership, coaching, and team development skills
Knowledge of medical necessity criteria, reimbursement principles, and managed care operation
Knowledge of clinical policies
Knowledge of CPT/HCPC Codes, and ICD-10
Proficient in claims processing systems and electronic medical record platforms
Strong problem-solving skills and the ability to identify discrepancies, assess risk, and recommend actionable solutions
Excellent verbal and written communication skills
Ability to work independently with a high degree of initiative, organization, and self-direction
Ability to work effectively with diverse teams in cross-functional work groups
Ability to multitask, re-prioritize tasking, and streamline day-to-day operations
High organizational and time-management skills
Familiarity with Centers for Medicare and Medicaid Services (CMS), Medi-Cal, or other regulatory frameworks
Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment
Ability to guide and support team members
Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision
Skilled in mediating disputes and resolving conflicts in a fair and constructive manner
Must have a deep understanding of financial principles
Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation
Strong presentation skills
Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges
Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals

Nice to have

Experience with Provider Dispute Review (PDR) processes
Experience applying clinical guidelines (e.g., InterQual, MCG, or internally developed criteria) in processes
Prior experience in payment integrity, compliance, or fraud, waste, and abuse (FWA) monitoring
Strong analytical and investigative skills with the ability to synthesize clinical and claims information into clear, defensible determinations
Advanced knowledge of medical necessity criteria tools such as InterQual or MCG
Extensive knowledge in claims reviews includes retrospective reviews, pre-payment claims review, and medical necessity determinations

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

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Manager, Utilization Management Claims Review

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