Health Plan Nurse Program Director (Utilization Management Director)

Contra Costa Health is offering an excellent opportunity forone (1) Health Plan Nurse Program Director within the Contra Costa Health Plan (CCHP) division: Utilization Management (UM)

Contra Costa Health Plan (CCHP) has been serving county residents with their health needs for over 50 years and was the first federally qualified state-licensed county-sponsored Health Maintenance Organization (HMO) in the United States. Established in 1973 CCHP continues to serve as the largest managed care health plan in Contra Costa County covering over 250000 residents.

CCHP is committed to ensuring equitable accessible and coordinated care for our diverse members. These leadership positions are critical to advancing CCHPs mission of providing affordable high-quality healthcare to all.

• Oversees utilization management functions including prior authorization review retrospective review concurrent review and discharge planning
• Supervises UM nurses and staff ensuring adherence to medical necessity standards and regulatory requirements
• Collaborates with Medical Directors and Chief Medical Officer
• Monitors UM operations for timeliness compliance and alignment with evidence-based practice guidelines
• Ensuring UM processes comply with all Medi-Cal (DHCS) Medicare (CMS) DMHC and NCQA requirements
• Collaborates closely with hospitals facilities and providers to support timely discharges reduce readmissions and improve care coordination
• Develops and refines UM policies workflows and decision-making standards to align with evidence-based practices and maintain regulatory compliance
• Prepares and presents UM reports to internal leadership external regulators and governing committees

• Experienced in Managed Care: Brings proven experience in medical management clinical operations and utilization management within a health plan or managed care setting
• Knowledgeable in Medicaid and Medicare:Demonstrates strong understanding of Medi-Cal and Medicare Programs including compliance operations and delivery systems
• A Critical Thinker: Able to analyze complex clinical and operational issues evaluate data and make sound evidence-based decisions
• Proactive:Anticipates needs takes initiative and drives solutions forward
• A Team Player: Works collaboratively across departments and with external partners to achieve shared goals
• A Leader: Skilled at directing teams and managing complex operations
• Action-Oriented: Able to prioritize and deliver results in a fast-paced environment
• A Strong Communicator: Comfortable interacting with staff providers members and external partners
• Equity-Minded: Committed to supporting Contra Costas culturally and linguistically diverse community
• Compliance-Focused: Knowledgeable in state federal and managed care requirements

• Directing and supervising clinical and administrative staff in either clinical operations or utilization management
• Providing clinical oversight coaching and mentoring to team members
• Developing and implementing operational programs policies and workflows
• Ensuring compliance with DHCS DMHC CMS and other regulatory requirements
• Coordinating with providers and partners to improve care access and outcomes
• Preparing reports and documentation for leadership regulators and accrediting bodies

• You will play a vital role in ensuring Contra Costa residents receive timely high-quality care
• You will lead teams that make a real difference in members health and well-being
• You will work in a mission-driven equity-focused organization with a supportive leadership team
• We offer generous benefits and a competitive retirement package!

• Navigating complex regulatory requirements while balancing operational needs
• Managing high-volume workloads and competing priorities
• Leading staff through change in a dynamic healthcare environment

• Critical Thinking & Problem Solving: Analytically and logically evaluating information identifying solutions and making sound decisions
• Legal & Regulatory Navigation: Interpreting and applying compliance requirements
• Leadership & Accountability: Guiding staff to achieve shared goals
• Strategic Thinking: Balancing short-term operational demands with long-term priorities
• Organizational Systems Thinking: Comprehending the organization as a system of integrated and interdependent functions

License Required:Candidates must possess and maintain throughout the duration of employment: a current valid and unrestricted Registered Nurse license issued by the California Board of Registered Nursing.

Applicants are required to attach a copy of their license and transcripts to their application.

Education: Possession of a Masters Degree in nursing hospital or health care administration or a closely related field from an accredited college or university.

Experience: Five (5) years of full-time experience or its equivalent as a Registered Nurse Utilization Review Nurse Discharge Planner Case Management Nurse or a Telephone Triage Registered Nurse in a healthcare or managed care setting (e.g. Preferred Provider Organization Managed Care Organization or Health Maintenance Organization) at least one (1) year must have been at a supervisory level.

Substitution: Possession of a Bachelors Degree in one of the fields noted above plus two (2) additional years of supervisory experience of the type noted above may be substituted for the Masters Degree. There is no substitution for the one (1) year of supervisory experience.

Possession of a Certified Case Manager (CCM) certification issued by the Commission for Case Manager Certification may be substituted for one (1) year of the required experience.

1. Application Filing and Evaluation: Applicants will be required to complete a supplemental questionnaire at the time of application. Applications will be evaluated to determine which candidates will move forward in the next phase of the recruitment process.
   
   
2. Training & Experience Evaluation: Candidates who clearly demonstrate that they possess the minimum qualifications will have their training and experience evaluated. The responses to the supplemental questions at the time of filing will be evaluated to determine each candidates relevant education training and/or experience as presented on the application and supplemental questionnaire. (Weighted 100%)