Senior Manager, Medical Policy

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive.  This philosophy enables us to create the health plan of the future and do our best work – Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP’s focuses on 5 Core Values in the workplace:

•    Integrity

•    Accountability

•    Collaboration

•    Trust 

•    Respect

Disclaimers:

•    Flexible work schedule is based on job duties, department, organization, or business need.

•    Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

The Senior Manager, Medical Policy is responsible for the development, management, and implementation of medical policies that guide clinical decision-making within utilization management. Under the direction of the Senior Director of Utilization Management, this role ensures that all medical policies align with clinical best practices, regulatory requirements, and organizational standards. The Senior Manager, Medical Policy collaborates with internal stakeholders and external entities to ensure consistent application and understanding of medical policies.

The successful candidate is a subject matter expert (SME) in regulations that govern the CMS Medicare and Medi-Cal Medical Policy, and in the application of operational strategies and tactics to maximize compliance with CMS and DHCS. The Senior Manager, Medical Policy will serve as a high-level individual contributor.

Amount of Travel Required: 5-10%

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

Job Function & Responsibilities

Program Planning and Design:

•    Lead the development and design of the Medicare D-SNP Utilization Management (UM) Program, ensuring alignment with federal and state regulations, organizational goals, and member needs.

•    Collaborate with cross-functional teams (e.g., clinical operations, compliance, legal, and IT) to create and implement effective utilization management strategies.

•    Identify key program objectives, performance metrics, and timelines to drive program success.

•    Subject matter expertise liaison to stakeholders’ enterprise-wide to provide strategic guidance to support and promote process deployment, refinement and execution to maximize program efficiencies.

Medical Policy and Procedure Development:

•    Directs the use and implementation of medical polices by establishing and maintaining dissemination channels and by promoting medical polices across the organization and with delegated provider partners. 

•    Ensures accurate interpretation of benefits by developing, implementing and maintaining the organization’s benefit interpretation functions. 

•    Improves efficiency and ensures accuracy of code related transactions such a claims processing, benefit interpretation, and clinical decision making by overseeing the standardization, implementation and ongoing updating of related coded sets throughout the organization. 

•    Develop and maintain policies and procedures related to utilization management for D-SNP members, ensuring compliance with all applicable Medicare regulations and guidelines.

•    Stays updated on changes in CMS (Centers for Medicare & Medicaid Services) policies, guidelines, and industry best practices, and adjust program policies as needed.

Operational Program Management:

•    Oversee day-to-day operations of the D-SNP Utilization Management Program, ensuring adherence to established processes and performance standards.

•    Monitor program performance and identify opportunities for improvement in both process and outcomes.

•    Track and report on key program performance indicators (KPIs), ensuring the efficient and effective management of resources.

•    Manage and resolve any operational challenges that may arise, ensuring continuity of care for members and compliance with regulatory requirements.

Collaboration with Healthcare Providers and Stakeholders:

•    Establish and maintain strong relationships with network providers, ensuring appropriate utilization of services and resources for D-SNP members.

•    Serve as the point of contact for providers, resolving utilization-related issues and promoting best practices in care coordination.

Utilization Review and Decision-Making:

•    Oversee the review of medical necessity and appropriateness of care for D-SNP members, ensuring decisions are consistent with evidence-based clinical guidelines.

•    Ensure timely and accurate decision-making regarding prior authorizations, concurrent reviews, and retrospective reviews.

•    Ensure that the program complies with all regulatory and contractual requirements related to utilization management.

Data Analysis and Reporting:

•    Prepare reports for senior management, including insights on utilization patterns, program outcomes, and areas for improvement.

Training and Education:

•    Provide ongoing training and support to internal staff, including care coordinators and other stakeholders involved in utilization management processes.

•    Ensure that all staff members are up to date on the latest policies, regulations, and best practices related to D-SNP utilization management.

Regulatory Compliance and Audits:

•    Ensure compliance with CMS requirements, state regulations, and organizational policies related to utilization management for D-SNP members.

•    Participate in internal and external audits and work with compliance teams to ensure that all program activities are well-documented and compliant.

Continuous Improvement:

•    Foster a culture of continuous improvement within the Utilization Management Program, incorporating feedback from stakeholders, performance data, and industry trends to drive process improvements and enhanced member care.

MINIMUM QUALIFICATIONS

Education & Experience: 

Required Education and Experience:

•    Bachelor's Degree in a Health-related field (preferred BSN)

•    Six years of experience in a Medicare Managed Care Organization

•    RN, California Board Certified Registered Nurse License – Required

•    Five years of experience interpreting and providing guidance on CMS regulations related to Medical Policies

•    Five years of experience with reimbursement, medical coding (CPT, ICD-9, ICD-10)

Preferred Education and Experience:

•    Master’s degree in a health-related field (MPH or MSN)

•    Five years of experience working in a highly matrixed, mission-driven organization

•    Experience with healthcare data including but not limited to care management, claims, authorizations, grievances and appeals

•    Comfortable presenting in front of leadership 

KNOWLEDGE, SKILLS & ABILITIES      

•    Working knowledge of Medi-Cal and related policy and regulations

•    Additional experience or related experience in managed care, Medi-Cal, Medicare, leadership experience, etc.

•    Ability to research and interpret complex statutes and regulations, and ability to dissect complex organizational and process issues.

•    Ability to hold others accountable for assigned work and outcomes.

•    Ability to be adaptable, flexible, capable of working both independently and in teams.

•    Ability to handle multiple tasks, prioritize and meet deadlines.

Technology & Software Skills: Advanced computer skills in MS Office products.

Certifications & Licenses: RN, California Board Certified Registered Nurse License – Required

Competency Statements

•    Management Skills - Ability to organize and direct oneself and effectively supervise others.

•    Decision Making - Ability to make critical decisions while following company procedures.

•    Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

•    Strategic Planning - Ability to develop a vision for the future and create a culture in which the long-range goals can be achieved.

•    Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.

•    Judgment - The ability to formulate a sound decision using the available information.

•    Communication, Written - Ability to communicate in writing clearly and concisely.  

•    Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.