Chinese Community Health Plan (CCHP) Jobs Hiring Now

The Utilization Management (UM) Senior Project & Data Specialist is responsible for providing high-level operational assistance to the Medical Management Department. Serving as the liaison between the UM Department and contracted medical groups and health plans, this position is responsible for coordinating the timely preparation and submission of reports and for preparing and coordinating documentation for health plan and regulatory audits. Monitors regulatory compliance of key UM and Provider Dispute Resolution (PDR) processes by conducting audits. Recommends new processes and procedures designed to improve efficiency or compliance. The UM Senior Project & Data Specialist must be extremely organized with outstanding attention to detail and be able to read and write English with excellent spelling and grammar

• Provide complex administrative support to the UM and PDR department, including project coordination and report preparation, ensuring deadlines are met.
• Serve as liaison between the Medical Management Department and health plans and medical groups by preparing documents and coordinating and organizing the collection of documents for annual and intermittent UM and PDR audits and handling other special projects as requested:
  • Gather and review policies and procedures and other information requested by auditors.
  • Pull and search from the electronic file all denials and service authorization requests required by auditors.
  • Assure that all SAFs or denials are in compliance with the audit requirements.
  • Make sure all clinical information is attached and reviewer signatures are printed in the service authorization requests
  • Assuring the correct template, language disclosure and accurate denial reason have been applied
• Responsible for notifying UM Director of any timeliness issues with other health plans or medical groups’ authorizations. Responsible for notifying Claims department of any delays in receiving authorization reports from contracted medical groups and health plans.
• Responsible for timely gathering of UM and PDR data and reports needed for internal and external audits which include, but are not limited to, CMS, DMHC, SFHP, and ATTEST data validation audits. Works closely with Compliance Officer and UM Director to ensure validity of data prior to submission.
• Ensure required documents are submitted to the CCHP QI Committee and Jade Health Care QA/UR Committee, approved and updated in applicable files. This includes gathering/revising UM & PDR policies and procedures and completing appropriate sections of quarterly work plans.
• Assure accurate and timely processing of the denial and pend letters and related correspondence by conducting monthly audits of denial/pend files in accordance with regulatory requirements. Prepare quarterly audit reports for submission to Committees. Communicate findings on a real-time basis to the UM nurses to prevent recurring deficiencies.
• Maintain updated knowledge in all aspects and transitions of departmental workflow, including state and federal requirements for UM and PDR functions.
• Monitor the ICE website for UM letter template updates.
• Serve as an internal resource (super-user) for department staff; assist others in learning functional features of Word, Excel, and Outlook as needed. Coordinate resolution of technical problems with the IT department as appropriate.
• Orient and train new UM coordinators and PDR Representative.
• Train new UM review nurses on the functions of the UM coordinators and the basics of our UM computer system.
• Train new PDR Specialist on the functions of the PDR Representative and the basics of our PDR computer system.
• Serve as subject matter expert and represent UM and PDR for core system build.
• Implement updates to the UM prior authorization process as directed, including documenting, disseminating and maintaining desk procedures to ensure coordination of operational changes.
• Implement updates to the PDR process as directed, including documenting, disseminating and maintaining desk procedures to ensure coordination of operational changes.
• Assist UM nurses to research health plan benefits, DOFRs, policies, criteria and/or guidelines.
• Facilitates or participates in process improvement initiatives by recommending improvements to business processes and policies and procedures. Maintains UM and PDR Department Master Policy and Procedure Manuals, ensuring they are the most up-to-date.
• May provide back-up administrative support for UM or QI Committees. Prepare and distribute agendas and supporting materials. Attend meetings and drafts minutes and correspondence. Communicates action items to responsible parties and follow-up on items to ensure completion.
• Also supports the Medical Director and the UM Director, which includes arranging meetings and calendar management, processing checks requests for vendor(s) invoices, and perform administrative duties as assigned.
• Accepts and performs other duties as assigned.

CORE COMPETENCIES

Must possess and consistently demonstrate the following competencies:

Management – Makes the best use of available time and resources. Acknowledges and corrects mistakes. Shows up to work on time, and follows instructions, policies, and procedures. Meets productivity standards, deadlines, and work schedules. Prioritizes tasks by importance and deadline. Displays an ongoing commitment to learning and self-improvement. Desiring and making an effort to acquire new knowledge or skills for work.

Leadership Effectiveness – Leads by example and sets standards for professional behavior. Helps those in need of assistance, regardless of rank. Offers help when needed. Identifies what needs to be done and takes action before being asked or required. Recognizes situations that warrant initiative and moves forward without hesitation. Displays a positive attitude about the work to be done, co-workers, customers, management, and policies. Conveys positive attitude in the process of change.

Decision Making and Judgment – Coordinates ideas and resources to achieve goals. Identifies, collects, and organizes data for analysis and decision-making. Shows insight into the root-causes of problems. Generates a range of solutions and courses of action with benefits, costs, and risks associated with each. Examines data to grasp issues, draw conclusions, and solve problems.

Teamwork – Conveying confidence in co-workers’ ability to be successful, especially with new and challenging tasks. Earns others’ trust and respect through consistent honesty and professionalism in all interactions. Builds constructive working relationships characterized by a high level of acceptance, cooperation, and mutual respect. Maintains an open, approachable manner, and treats others fairly and respectfully. Preserves others’ self-confidence and dignity, and shows regard for their opinions. Promotes cooperation and commitment within a team to achieve goals and deliverables.

Continuous Improvement – Adapting to and working with a variety of situations, individuals, and groups. Demonstrates openness to new organizational structures, procedures, and technology. Openness to different and new ways of doing things. Willingness to modify one’s way of doing things. Diligently attends to details and pursues quality in accomplishing tasks. Develops fresh ideas that provide solutions to all types of workplace challenges.

Communication – Keeps manager informed about progress and problems. Ensures that others involved in a project or effort are kept informed and developments and plans. Allows others to speak without unnecessarily interrupting them. Gives the speaker undivided attention and appears interested in the message (e.g., maintains eye contact, nods). Gets along and interacts positively with co-workers and others. Asks and answers questions that enhance the clarity, quality, and reliability of information.

Work Product Quality – Adheres to all workplace and trade safety laws, regulations, standards, and practices. Displays openness to different or new ways of doing things and sees multiple perspectives. Responds positively to change, embracing and using new practices or values to accomplish goals and solve problems. Respects and maintains confidentiality. Tells the truth and is honest in all dealings. Encourages and supports others at work. Focuses on results and desired outcomes and how best to achieve them in order to get the job done. Willingly puts in extra time and effort in crisis situations; goes the “extra mile” to ensure the goal is met. Defining tasks and milestones to achieve objectives, while ensuring the optimal use of resources to achieve those objectives.

Customer Service – Builds and maintains customer satisfaction with the products and services offered by CCHP. Meeting and exceeding customer needs while cultivating relationships that secure commitment and trust. Seeks customer feedback and ensures needs have been fully met. Be positive when interacting with customers. Delivers products and services when and where the customer needs them. Engages customer in identifying issues, options, and desired outcomes. Develops a clear picture of the needs and best options from the client/customers’ perspective. Remains committed to helping the client long after initial solutions have been applied. Follows up to make sure desired outcomes are realized. Acts proactively, recognizing important trends that will affect customers. Communicates those trends so clients can better prepare to meet new challenges. Develops new services and service models in line with those needs. Anticipates and recognizes the concerns of others, even if those concerns are not openly expressed. Provides excellent services to internal and external customers

• Bachelor’s degree preferred or equivalent experience
• Advanced Excel skills required
• Two years experience working in a managed healthcare environment, preferably in the area of UM, QA or auditing
• Must be detail oriented
• Strong verbal and written communication skills required.

• Able to lift up to 30 pounds
• Use proper body mechanics when handling equipment
• Standing, walking and moving 50% of the day.

Complies with CCHP Compliance Handbook including Code of Ethics and all statutes, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs.

Starting at $35.37 – $53.01 per hour.

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.