Manager, Utilization Management Claims Review

Manager, Utilization Management Claims Review Job Category: Clinical Department: Utilization Management Location: Los Angeles, CA, US, 90017 Position Type: Full Time Requisition ID: 13083 Salary Range: $117,509.00 (Min.) - $152,762.00 (Mid.) - $188,015.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Manager, Utilization Management Claims Review is responsible for overseeing the clinical and operational functions of the Claims Review team. This position provides leadership and strategic direction to ensure accurate clinical claim determinations, regulatory compliance, and adherence to established clinical policies. The Manager drives payment integrity initiatives through effective oversight of pre-payment review, retrospective review, and Provider Dispute Review (PDR) processes while ensuring regulatory timeframes and quality standards are consistently met. The Manager, Utilization Management Claims Review partners with internal departments and executive leadership to promote effective workflows, mitigate fraud, waste, and abuse (FWA), and support high-quality, cost-effective care delivery and organizational performance goals. The Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Participates and makes recommendations on the department's strategic planning and/or long-term decision-making. Duties Manage staff, including, but not limited to monitoring of day-to-day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others. Ensure quality standards are met by regularly reviewing claim files, clinical decisions, and Provider Dispute Review (PDR) determinations to confirm compliance with company policies, clinical guidelines, and regulatory requirements. Identify trends or errors and implement improvements to increase accuracy and consistency. Establish team goals, monitor performance metrics, and ensure productivity and quality standards are met. Support recovery efforts and corrective action plans related to inappropriate billing or utilization patterns. Oversee workflow and queue management to ensure claims and PDR requests are completed within required regulatory timeframes, including monitoring workload distribution. Ensure adequate staffing resources and prevent backlogs or compliance risks. Ensure clinical policies are applied correctly and consistently, including policies designed to prevent fraud, waste, and abuse (FWA). Potential FWA concerns are identified and escalated in partnership with Compliance and the Special Investigations Unit (SIU). Duties Continued Support audits, regulatory readiness, and cross-functional initiatives to maintain compliance with state, federal, and accreditation standards. Implement and monitor adherence to Utilization Management (UM) policies, procedures, and turnaround time requirements. Work cross-functionally with leadership to ensure claims are aligned, and well-received by internal and external stakeholders. Foster teamwork, accountability, and continuous improvement while ensuring departmental goals align with organizational priorities. Manage complex projects, engaging and updating key stakeholders, developing timelines, leading others to complete deliverables on time and ensure implementation upon approval. Responsible for reporting, budgeting, and policy implementation. Perform other duties as assigned. Education Required Bachelor's Degree in Nursing In lieu of degree, equivalent education and/or experience may be considered. Education Preferred Master's Degree in Nursing Experience Required: At least 6 years of experience in Clinical Nursing. At least 3 years of experience with Medi-Cal and Medicare in a managed care environment. At least 4 years of leading staff, supervisor/management experience. Experience in performing and creating clinical documentation. Experienc