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UCLA Health Quality and Credentialing Manager in Los Angeles, California

Responsibilities

Take on a key role within a world-class health organization. Help ensure the consistent delivery of exceptional patient care. Take your professional expertise to the next level. UCan do all this and more at UCLA Health.

In this key role, you will oversee, manage and supervise our Quality Management and Credentialing teams. This involves designing, modifying and proposing operational systems and processes for effectively and efficiently managing and coordinating department activities and objectives. You will ensure consistent execution on performance improvement programs and initiatives, including HEDIS, Pay for Performance, CMS Star, and HCC coding. You will also be responsible for maintaining compliance with all contractual obligations, state regulations and NCQA standards. You will ultimately be accountable for these critical functions:

  • Quality Management Program

  • Complaints, Appeals and Grievances

  • Medical Record and Site Review

  • Credentialing Program

  • Medical Review/Peer Review

  • Performance Improvement Initiatives/Programs

  • Compliance

Qualifications

We're seeking an independent, detail-oriented individual with:

  • LVN license - RN license preferred

  • A minimum of four years of clinical experience providing direct patient care and quality management, disease management or case management

  • Previous managed care experience in a complex and diversified healthcare or health insurance company

  • At least two years of management/supervisory experience

  • In-depth knowledge of quality management and performance improvement concepts (e.g., Pay for Performance, HEDIS and CMS Stars, etc.)

  • Knowledge of CMS HCC Risk Adjustment and Coding guidelines desired

  • Thorough understanding of relevant regulatory standards (e.g., HIPAA, NCQA, DMHC, CMS, etc.)

  • Proficiency with Microsoft Office

  • Background with Microsoft Access and/or SQL a plus

  • Experience using provider credentialing management software (e.g., Morrisey, CACTUS, HealthLine, Echo, etc.)

  • Familiarity with CPT, ICD-9/ICD-10, and HCPCS codes

  • Sound judgment and the ability to think 'outside the box'

  • Strong communication, presentation, analytical, problem-solving and leadership skills

  • Ability to read and analyze business periodicals, professional journals, technical procedures, health plan requirements and state/federal regulations

  • Willingness and ability to occasionally travel

UCLA Health is a world-renowned health system with four award-winning hospitals and dozens of primary care practices, specialty practices, urgent care centers and other ancillary locations throughout metro Los Angeles. We are also home to the David Geffen School of Medicine, an internationally-respected leader in medical education and research. Through the efforts of our outstanding people, we have become Los Angeles' trusted provider of exceptional, compassionate patient care. If you're looking to experience greater challenge and fulfillment in your career, UCan at UCLA Health.

UCLA is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veteran status.

UCLA Health welcomes all individuals, without regard to race, sex, sexual orientation, gender identity, religion, national origin or disabilities, and we proudly look to each person’s unique achievements and experiences to further set us apart.

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