Delegation Oversight Manager

Now hiring a Manager-Utilization Management Contract Quality and Oversight

The Manager, UM Contractor Quality and Oversight is responsible for coordinating internal and external utilization management audits and for performing direct oversight of all sub-contracted utilization management (UM) services for delegated and non-delegated functions, including, but not limited to developing and maintaining audit procedures, tools, and correspondence; establishing and maintaining effective and professional relationships with UM sub-contractors; and leading internal and external audit and monitoring fulfillment activities.. Ensures UM sub-contractor operations comply with client agreements, applicable state and federal regulations, laws and National Committee of Quality Assurance (NCQA) accreditation programs. Ensures that services to members are delivered in accordance with client contracts and applicable state and federal regulations, laws and accreditation programs. Responsibilities include ongoing monitoring and auditing of UM sub-contracted operations; development and maintenance of policies and procedures for leadership approval; development and monitoring of corrective action plans; reporting progress of corrective action plans to internal and external entities as needed. Interfaces closely with UM Director and management, Compliance, Regulatory Operations, Appeals & Grievance, Program Integrity, Quality Management and other departments to ensure UM sub-contracted operations adhere to client contractual requirements; including state and federal regulations and accreditation programs. Serves as a liaison between UM operations, UM sub-contractor, Regulatory Operations Managers, Clinical Quality and Utilization Management Committee, Delegation Oversight Committee, FDR Committee, and the client Compliance Officer and client leaders and stakeholders. Responsible for maintaining relationships with key quality assurance stakeholders and is primary liaison with auditors, regulators, accreditors, compliance personnel and clients as related to quality assurance matters. The Manager, UM Contractor Quality and Oversight serves as a subject matter expert for UM regulatory requirements. operational processes, and sub-contractor activities. Responsible for the selection, hiring, and training of staff who support UM contractor quality and oversight. Provides leadership consistent with organizational strategy and works to achieve exceptional outcomes with UM contractors.

How you belong matters here.

We value our employees' differences and find strength in the diversity of our team and community.

At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.

Why Join Us

• Full Time - Exempt: Yes
• Job is based Rev Hugh Cooper Admin Center
• Work hours: Days
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.

Ideal Candidate: Strong interpersonal, verbal and written communication skills.  Supervisory experience preferred. Experience managing contracts and/or vendors.  

• Bachelors degree required and five+ years experience in managed care required (preferably in quality assurance, utilization management, or compliance)
• Equivalent experience in auditing/compliance/ health care.
• Requires detailed coordination, organizational and project management skills.
• Experience in process improvement methodologies. Must be able to work cooperatively with other employees and departments and function effectively under pressure.
• Familiarity with Windows and Microsoft Office products.

• Demonstrates the ability to operate with a high-level of autonomy while achieving the primary functions described herein.
• Performs complex analysis of regulatory, accreditation, and contractual requirements as well as operational processes and determines strategies for monitoring, measuring, and reporting compliance outcomes.
• Develops, executes, and maintains audit procedures, tools, and correspondence in support of internal monitoring projects, external audit fulfillment, and UM sub-contractor management and oversight.
• Demonstrates the ability to develop, foster, and maintain professional and effective relationships with UM sub-contractors, including high-quality written and verbal communications; navigation of difficult and challenging conversations that achieve expected outcomes while respecting the needs, views, and opinions of all participants; and modeling Presbyterians core values of CARES behaviors and Promise expectations to facilitate high-quality service outcomes from our delegate partners.
• Develop and maintain UM Sub-Contractor Oversight Program to ensure compliance with policies, contractual obligations, compliance program and regulatory requirements. Activities include ongoing monitoring, auditing, reporting, data analysis, issue resolution, corrective action and relationship management and ongoing communication with UM sub-contractors. Maintain records of oversight.
• Develop schedule and coordinate resources for internal monitoring and audits of UM sub-contractors. Coordinate resources and audit responses to external regulatory agencies and accreditation bodies. Maintain records of monitoring and audits.
• Conduct and/or participate in mock audits as needed for UM sub-contractor related processes and actively prepare/participate in CMS/DHS/NCQA audits.
• Develop schedule and maintain UM sub-contractor oversight and management policies to ensure compliance with business requirements, client agreements and applicable Federal and State regulations and accreditation standards.
• Develop/approve corrective actions plans (CAPs) as needed, to include specific areas of improvement, assigned accountability, and timelines. Maintain records of CAPs.
• Serve as point of contact for UM sub-contracted services and report audit findings, present corrective action plans, and report progress to appropriate departments/personnel/committees.
• Serve as liaison between PHP and UM sub-contractor to ensure timely reporting, acknowledgement and resolution of complaints / grievances and suspected fraud and abuse cases which are reported directly to the sub-contractor.
• Monitors state and federal rule-making proposals and coordinates review and response as appropriate.
• Performs a comprehensive regulatory review and analysis of UM regulatory requirements and disseminates regulatory updates to UM leadership team and UM sub-contractors.
• Assists UM leaders to ensure the department is updating, revising, training and communicating policies and procedures.
• Oversees delegation, contractor, and business partner relationships and oversight.
• Directs regulatory, training, and process monitoring guidance for third party vendors.
• Organizes and coordinates cross functional teams to address regulatory issues that cross multiple departments or entities.
• Monitors trends in complaints which impact access, availability and quality of services and collaborate with sub-contractor to effect improvement.
• Directs and oversees the work of Quality Assurance Auditors performing work in support of UM sub-contractor management and oversight accountabilities.
• Manages preparation for external regulatory audits and accreditation surveys, including the interpretation of standards and development of mechanisms for completing audit and survey activities. Manages activities and prepares files and documents to support regulatory audits and accreditation surveys.
• Participates in risk assessments to ensure relevant risks are incorporated.
• Advises on regulatory, accreditation, and contractual requirements as a resource for policies, procedures, and operational changes related to utilization review.
• Promotes system-wide strategies and compliance with regulatory, accreditation, and contract compliance.
• Mentors staff on regulatory, accreditation, and contract requirements.
  
  

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

Inclusion and Diversity
Our culture is one of knowing and respecting our patients, members, and each other. We capture this in our Promise and CARES commitments.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

USD $59.41/Hr.

The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.