Manager, Utilization Management, Quality and Oversight
Capital Blue Cross
full-time
Posted on:
Location Type: Remote
Location: Pennsylvania • United States
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Salary
💰 $83,800 - $157,890 per year
About the role
- Provides clinical oversight and management of UM audit activities
- Leads and coordinates UM audit activities
- Audits UM activities to ensure compliance with established timeframes and standards of performance in accordance with the National Committee for Quality Assurance (NCQA), the Department of Health (DOH), Centers for Medicare and Medicaid Services (CMS), and other state and federal regulatory requirements
- Prepares and presents audit findings to UM leadership, corporate and Medicare compliance and/or the Quality and Accreditation team as appropriate
- Ensures sample size and frequency of audits is appropriate for the population
- Monitors vendor compliance activities
- Responsible for CMS reporting requirements including: Part C Organization Determinations, Appeals, and Grievances (ODAG) report review and auditing for Capital and delegated UM vendors
Requirements
- Minimum of (5) years of successful management experience in a healthcare-related field
- Minimum of (3) years in medical management activities, including UM
- Knowledge of health plan regulatory and coverage requirements, including CMS, NCQA, JCAHO, and the DOH
- Knowledge of the Mental Health Parity and Addictions Equity Act (MPHAEA)
- Licensure as a health care professional
- Minimum requirements include a bachelor’s degree in a healthcare-related field
- Master’s Degree is preferred
Benefits
- Medical, Dental & Vision coverage
- Retirement Plan
- Generous time off including Paid Time Off, Holidays, and Volunteer time off
- Incentive Plan
- Tuition Reimbursement
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical oversightmanagement of UM audit activitiesaudit compliancereporting requirementssample size determinationvendor compliance monitoringaudit findings presentationmedical management activitieshealth plan regulatory knowledgecoverage requirements knowledge
Soft Skills
leadershipcoordinationcommunicationorganizational skillspresentation skills
Certifications
licensure as a health care professional