POSITION DESCRIPTION

　　POSITION TITLE: Medical Management Services Manager

　　EXEMPT STATUS: Exempt

　　SALARY RANGE: $85,000 - $112,000

　　DEPARTMENT: Medical Management Services

　　REPORTS TO: Director Medical Management Services

　　POSITION SUMMARY:

　　This great opportunity is ideal for a detailed oriented RN that is interested in moving into an administrative role. Our client is looking for someone that has auditing experience, leadership qualities, and has a strong focus on quality assurance.

　　You would be responsible for oversight and management of health policies for a large insurance provider. You'll also be running quality improvement programs and initiatives to ensure compliance with state and federal requirements.

　　Under the direction of the Director of Medical Management and the Chief Medical Officer, the Medical Management Manager will work collaboratively with staff and its contracted Plan Administrator to monitor and report on clinical, service, and quality related data and issues and implement improvements through policy and process enhancements.

　　ESSENTIAL DUTIES & RESPONSIBILITIES:

　　• Manage and oversee the review and revision of Medical Management policies and procedures to ensure they address current and new applicable statutes and/or regulations.

　　• Manage directly reporting Medical Management staff and oversee department activities.

　　• Manage the review, preparation, and submission of documents and policies for the DHCS/DMHC Medical Audits.

　　• Lead the delegation audit process, develop reports regarding audits, and analyze, track and trend audit findings.

　　• Coordinate preparation for the Appeals and Grievances Work Group including draft agenda & minutes, report gathering and follow up.

　　• Prepare and review required reports, program documents and workplans as requested.

　　• Support and participate in Quality Improvement projects and teams including meeting agendas, tracking logs and regulatory submissions.

　　• Attend Quality Improvement/Utilization Management Committee, QI Work Group, Monthly Case Management, Utilization Management.

　　• Interact with HNCS staff as necessary in fulfilling duties of this job description.

　　• Function as back up for the Appeal & Grievance file transfer process including auditing the cases to ensure files are complete and ready for regulatory audits.

　　• Other duties as assigned by the Director.

　　MINIMUM QUALIFICATIONS/EDUCATION:

　　• Registered Nurse required.

　　• Healthcare related bachelor’s degree.

　　• Master’s degree –MPH or MPA-- is highly desirable.

　　• Certification in Healthcare Quality (CPHQ) desirable.

　　L ICENSES:

　　• RN license as appropriate

　　• Current driver’s license

　　EXPERIENCE:

　　• Five years progressive experience in Healthcare Quality Improvement and/or Project

　　Management.

　　• Previous managerial experience preferred.

　　• Minimum of two years’ experience in healthcare service environment.

　　KNOWLEDGE, SKILLS & ABILITIES:

　　• Strong knowledge of healthcare federal, state and NCQA standards and regulations.

　　• Knowledge of Managed Care Operations.

　　• Ability to effectively develop, analyze, interpret, and communicate healthcare data reports and processes.

　　• Effective verbal and written communication skills.

　　• Strong organizational, analytical and problem-solving skills.

　　• Must be proficient in Microsoft Office: Word, Excel, PowerPoint, Access and Outlook.

　　• Possess the ability to effectively organize and prioritize projects and multi-task.

　　• Ability to take initiative and work independently.

　　• Team player who can establish and maintain effective working relationships at all organization levels.

　　• Exercise a high degree of maturity, integrity, loyalty, initiative, creativity and sound judgment.

　　Benefits

　　At Maxim Healthcare Staffing, we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:

　　Competitive pay & weekly paychecks

　　Health, dental, vision, and life insurance

　　401(k) savings plan

　　Awards and recognition programs

　　*Benefit eligibility is dependent on employment status.

　　About Maxim Healthcare Staffing

　　Maxim Healthcare Staffing has been making a difference in the lives of our patients, caregivers, and employees for more than 30 years. Our nationwide suite of services includes home healthcare, companion and behavioral care, healthcare staffing, and workforce solutions. Maxim's commitment to customer service, compassionate patient care, and filling critical staffing needs makes us a trusted partner wherever healthcare is needed.

　　Maxim Healthcare Staffing is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected Veteran status, age, or any other characteristic protected by law.