Manager, Utilization Management Nurse Management- Appeals and Grievances

Your Role 

The Medical Care Solutions Appeals and Grievance team is hiring an RN manager who will be responsible for leading the clinical appeals and grievance team for MediCare and Medi-Cal. The RN manager will report to the Sr. RN Manager. In this role you will be responsible for inventory management, staffing, transformation, special projects, and compliance. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work 

In this role, you will: 

• Establish operational objectives for department or functional area and participate with other managers to establish group objectives 

• Be responsible for team, department or functional area results in terms of planning, cost in collaboration with Sr Manager 

• Participate in the development and implementation of the annual budget under the direction of Sr Manager / Director 

• Ensure work-flow procedures and guidelines are clearly documented and communicated 

• Interpret or initiate changes in guidelines/policies/procedures 

• Maintain regulatory compliance

• Develop and implement recommendations for improvement of quality and production

• Stay current on regulatory changes and industry requirements

• Responsible for reporting, analysis, and oversight metrics

• Be collaborating with internal business partners

Your Knowledge and Experience 

• Bachelors of Science in nursing or advanced degree preferred

• Requires a current active California RN license

• Requires at least 7 years of prior relevant experience including 3 years of management experience gained as a team leader, supervisor, or project/program manager

• Medi-Care and Medi-Care experience required

• Understands staff scheduling, prioritizing, coaching, and process execution

• Experience with data analysis, trending, and inventory management required

• Regulatory audit experience with file preps, presenting, and CAP resolution required

• Requires experience with staff development and performance management

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.