Job description

The Director of Utilization Management provides hands-on, in addition to, global operational expertise for the company’s Utilization Management Department.

This department includes case management services (inpatient, subacute and outpatient), referral authorization of ambulatory services, education services and disease management services for patients within global risk contracts. The Utilization Management Director is responsible for training and managing a high functioning Utilization Management Team that ensures, and improves upon, efficiency, quality of care, resource utilization, clinical documentation, service excellence, work flow, and regulatory requirement satisfaction. The Director of Utilization Management collaborates with clinical, administrative and executive leadership to ensure organizational goals are met and that risk share performance incentives increase revenue. The Utilization Management Director will also collaborate with outside entities/vendors appropriately to maximize benefits of ancillary services within risk based contracts. The Utilization Management Director must understand thoroughly and be able to communicate Medicare Advantage regulations and CMS guidelines. The Director of Utilization Management is accountable for policy and procedure drafting and implementation, departmental maintenance/readiness for internal and external audits and administration of industry best practices as they evolve.

Minimum Required Education, Experience & Skills

• BSN required; Master's (MSN,MHA,MBA, MPH) preferred
• Current TX licensure required
• Requires minimum 5 years of Utilization Management experience with a large medical group or health plan
• Proven experience managing operations (clinical and nonclinical) within a Medicare/Medicare Advantage managed care environment
• Experience with Medicare/MA managed care audits and regulations is required
• Experience with Quality Assessment and Process Improvement projects
• In depth knowledge of all aspects of commercial and Medicare/MA managed care medical management to include treatment guidelines such as Milliman, Interqual or other practical management guidelines
• Experience with Federal, State, large health plan and accreditation organizations
• Previous leadership over a Utilization Management team
• Effective and proactive use of performance metrics
• Demonstrated experience with writing and implementing operational policy and procedures
• Familiarity with data reporting platforms used within utilization management to not only interpret but also extract meaningful data
• Strong reporting and presentation skills
• Excellent interpersonal abilities
• Strong patient service standards
• Strong clinical background.
• Prior HMO/Managed Care experience (Medicare and Commercial)

Responsibilities

• Develop and implement effective administration of Utilization Management policies and procedures aligned with federal, state, and health plan contract and regulatory guidelines
• Direct Utilization Management and Disease Management projects and processes and evaluate effectiveness with proven ability to adjust programs to achieve desired outcomes.
• Provide clinical support and education within and outside the Utilization Management department
• Facilitate consistent, cost-effective and proactive utilization management through analysis of defined metrics
• Understand the roles and relationships among medical management, quality initiatives (HEDIS, CAHPS, Stars), and wellness programs within the medical group
• Report utilization data and analyses to executive leadership & UM committee
• Prepare for and participate in regulatory audits
• Implement and continuously improve upon standard operational procedures that are consistent with federal, state, and health plan requirements
• Evaluate and monitor regulatory quality measures, case management, utilization management and Physicians expectations
• Coordinate with other operational departments to identify workflow best practices and develop and implement improvement initiatives
• Establish and maintain strong working relationships with Providers to ensure organizational performance goals and quality measures are met
• Conduct monthly staff meetings and associate 1:1's and provide training, coaching and counseling as needed
• Ensures that the case management program provides for appropriate and cost effective medical services, behavioral health services, and medically-related social services and that they are identified, planned and obtained where needed.

Working Conditions/Physical Requirements: Requires working under stressful conditions where constructive criticism from others is encouraged. Requires working extended or irregular hours (including evenings and occasional weekends) as the medical group determines necessary or desirable to meet its business needs and/or the needs of its patients. Requires prolonged sitting, some bending, stooping and stretching and occasional lifting up to 50 pounds. Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment. Requires normal range of hearing and eyesight to record, prepare and communicate appropriate reports. Normal office environment.

Job Type: Full-time

Schedule:

• Monday to Friday

Work Location: In person

seankuhnke.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, seankuhnke.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, seankuhnke.com is the ideal place to find your next job.