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.

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 a