Job Description

Payroll Title:
MGD CARE SUPV 2
Department:
PHSO - MSO
Salary Range
Commensurate with Experience
Worksite:
Greenwich Drive
Appointment Type:
Career
Appointment Percent:
100%
Union:
Uncovered
Total Openings:
1
Work Schedule:
Days, 8 hour days, Monday - Friday

As a federally-funded institution, UC San Diego Health maintains a marijuana and drug free campus. New employees are subject to drug screening.

#119113 Systems/Benefits/AP Recovery Mgr. - Hybrid/Remote

Extended Review Date: Thu 11/17/2022

UC San Diego values equity, diversity, and inclusion. If you are interested in being part of our team, possess the needed licensure and certifications, and feel that you have most of the qualifications and/or transferable skills for a job opening, we strongly encourage you to apply.

For the safety and well-being of the entire university community, the University of California requires, with few exceptions, that all students, faculty and staff be vaccinated against the COVID-19 virus and influenza before they will be allowed on campus or in a facility or office. For more information visit: Flu Vaccine Mandate / COVID Vaccine Policy

This position will remain open until a successful candidate has been identified.

Special Selection Applicants: Apply by 10/03/22. Eligible Special Selection clients should contact their Disability Counselor for assistance.

This position will work a hybrid schedule which includes a combination of working both onsite at Greenwich Drive and remote.

DESCRIPTION

Reporting to the Director, Network Management Operations, the Systems/Benefits/AP Recovery Manager is responsible for the overall management, direction and oversight of the multi-disciplinary PHSO Managed Care Systems/Benefits/AP Recovery team. Incumbent will ensure timely and accurate Epic system record management for AP claims and management of AP Recovery programs, eligibility, system benefits, and AP check runs in compliance with health plan, CMS and DMHC guidelines. The manager establishes benchmarks and quality control audit programs along with necessary reporting to validate accuracy of all functions and serves as a subject matter expert in all associated operational areas, providing guidance and support to the team, facilitating training and identifying process improvement opportunities to streamline and automate work as needed.

Key Responsibilities:

Operations and Delegation Compliance:

  • Oversees the interpretation and implementation of regulations and mandates pertinent to network operations to ensure regulatory and payor delegation compliance.
  • Implements effective quality control and audit programs along with necessary reporting to validate accuracy of all functional areas.
  • Works in collaboration with other department management and staff to develop corrective action plans in response to identified deficiencies; implements corrective actions; and continuously monitors to ensure compliance.
  • Identifies error trends, defects and process improvement opportunities.
  • Collaborates with management to improve network operations by identifying application or system issues, and recommends and implements innovative solutions.
  • Establishes and maintains documentation related to departmental processes and workflows (policies and procedures, reference tools, production reports) to ensure compliance with best practices, production standards, federal and state regulations, and health plan policy and delegation requirements.

Team Support and Management:

  • Provides leadership, direction and guidance to the Systems/Benefits/AP Recovery team and establishes metrics to ensure departmental goals and objectives are being met.
  • Manages inventory and assignments to balance workloads and resources.
  • Supports and leads team members in the identification and implementation of improved processes, increased automation, and improved system accuracy.
  • Assists in validation and testing to ensure AP system is configured and maintained appropriately to support accurate referral and claim processing and adheres to regulatory requirements.
  • Advises staff of all procedural changes in a timely manner, documents and ensures changes are implemented promptly and effectively.
  • Oversees AP Check Run processes and provides intervention as needed for this critical function to ensure inquiries and issues are resolved promptly and accurately.
  • Coaches and develops staff; assists in defining goals and establishes trust.

Collaboration and Communication:

  • Provides ongoing communication to team members regarding organizational and operational changes.
  • Leads and contributes to various projects representing PHSO Managed Care network operations, ensuring deliverables are met timely and work is of high quality and integrity.
  • Represents network operations in internal and external meetings, audits and joint operation committee meetings; maintains positive relationships with key customer contacts.

MINIMUM QUALIFICATIONS

  • Nine (9) years of related experience working in an MSO or health plan for the administration of capitated, delegated HMO payor agreements (extensive understanding of managed healthcare operations), education/training, OR a Bachelor’s degree in related area plus five (5) years of related experience/training working in an MSO or health plan for the administration of capitated, delegated HMO payor agreements (extensive understanding of managed healthcare operations).

  • Experience and solid knowledge of the principles, concepts, systems, processes, quality improvement plans, and best practices needed for effective and successful operations in managed care network operations. Ability to train and guide employees on techniques.

  • Strong communication and interpersonal skills to communicate with all levels of staff, both verbally and in writing.

  • Excellent time management, organizational and follow-up skills to prioritize and complete tasks within set timelines.

PREFERRED QUALIFICATIONS

  • Understanding of and experience with HMO claims adjudication.

  • Epic Tapestry experience.

  • Epic Certification.

SPECIAL CONDITIONS

  • Must be able to work various hours and locations based on business needs.

  • Employment is subject to a criminal background check and pre-employment physical.


Job offer is contingent on successful engagement in the UC COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

If applicable, life-support certifications (BLS, NRP, ACLS, etc.) must include hands-on practice and in-person skills assessment; online-only certification is not acceptable.

UC San Diego Health is the only academic health system in the San Diego region, providing leading-edge care in patient care, biomedical research, education, and community service. Our facilities include two university hospitals, a National Cancer Institute-designated Comprehensive Cancer Center, Shiley Eye Institute, Sulpizio Cardiovascular Center, the only Burn Center in the county, and and dozens of outpatient clinics. We invite you to join our team!

Applications/Resumes are accepted for current job openings only. For full consideration on any job, applications must be received prior to the initial closing date. If a job has an extended deadline, applications/resumes will be considered during the extension period; however, a job may be filled before the extended date is reached.

To foster the best possible working and learning environment, UC San Diego strives to cultivate a rich and diverse environment, inclusive and supportive of all students, faculty, staff and visitors. For more information, please visit UC San Diego Principles of Community.

UC San Diego Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity or sexual orientation. For the complete University of California nondiscrimination and affirmative action policy see: http://www-hr.ucsd.edu/saa/nondiscr.html

UC San Diego is a smoke and tobacco free environment. Please visit smokefree.ucsd.edu for more information.

Application Instructions

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