Utilization Management Market Operations Manager, RN Preferred

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🎰 Nevada – Remote

🎰 Nevada – Remote

💵 $83k - $132.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

⚙️ Operations

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Manage operational activities for Utilization Management and Appeals for specified lines of business • Develop and maintain policies and standard operating procedures • Review team metrics and oversee statutory reporting • Oversee committee reviews, audit preparation, presentations, and annual program requirements • Use process controls to achieve operational excellence • Work with clinical leadership to close operational procedure variances • Drive process improvement using continuous improvement frameworks • Manage policy and process changes resulting from regulatory and compliance requirements • Educate, mentor, and train staff and clinical leaders • Manage internal and external relationships to improve standardization and collaboration • Define and use outcome measurements to drive success • Design future-state operating models • Manage cross-divisional and cross-functional process improvement opportunities • Oversee change management initiatives affecting the department • Perform other duties as requested

🎯 Requirements

• Associate degree in Nursing or advanced degree in Psychology required • Minimum five years of experience in Utilization Management or related operations required • Managed Care experience required • Experience with analysis, data, and reporting required • Demonstrated change management and continuous improvement leadership skills required • Current, unrestricted Registered Nurse (RN) licensure or Licensed Psychologist license in state of practice required • Proficient use of Microsoft Office Suite, including Word, Excel, PowerPoint, Outlook, and Visio • Knowledge of NCQA and/or CMS accreditation and audit standards • Knowledge of regulatory reporting, compliance requirements, and auditing procedures • Decision-making, problem-solving, critical-thinking, planning, and resolution skills • Strong oral, written, and interpersonal communication skills • Proficiency with quality improvement, performance improvement, and operations • Ability to manage multiple competing goals and collaborate with multidisciplinary departments • Ability to work independently and within a team • Strong attention to detail and time management skills • Customer service and de-escalation skills • Ability to gather and analyze data and create meaningful action items • Ability to review and implement evidence-based trends • Accreditation, auditing, process improvement, quality control, or process standards experience preferred • Six Sigma or project management certifications are a plus • Must live in Nevada and hold the required state license

🏖️ Benefits

• Base salary range of $83,000.00–$132,800.00 per year • Potential bonus tied to company and individual performance • Substantial and comprehensive total rewards package • Employee well-being support