Director, Utilization Management & Operational Integrity

Medical Mutual•Cleveland, OH

8d•Hybrid

About The Position

Directs operations related to Commercial and Medicare acute and post-acute care services to advance evidence-based policies, protocols, and practices to ensure efficient use of health care services and adherence to corporate and regulatory standards. Directs education, training, and auditing of all clinical services and operational staff.

Requirements

Bachelor of Science in Nursing required.
8 years progressive experience in managed care utilization management, 5 years of which are in a leadership or project management capacity.
Registered Nurse with current unrestricted license in state of residency required.
Ability to obtain Ohio RN or Multi-state RN Compact License within 60 days of date of hire.
Ability to obtain additional RN licensure for multi-state member management within 90 days of hire.
Comprehensive knowledge of NCQA accreditation standards and CMS regulations, HIPAA compliance and the ability to apply advanced concepts to Company operations.
Strong computer skills (Microsoft Office, including Outlook, Excel, PowerPoint, Word).
Demonstrated success with improving achieving productivity for authorization requests.
Strong demonstrated communication and presentation skills.
Strong knowledge of clinical claim management including ICD 10, CPT and HCPCS codes.
Strong knowledge of health insurance benefits and network plan designs.
Abiltiy to apply knowledge of health plans and industry trends to achieve positive outcomes.
Thorough understanding of clinical knowledge, members’ specific health plan benefits, and efficient care delivery processes.
Knowledge of care delivery systems and continuum of acute through post-acute care.

Nice To Haves

Master’s degree preferred.
Experience with process improvement techniques preferred.

Responsibilities

Analyzes trends and identifies/implements departmental initiatives based upon data provided through the reporting of production, quality, financial and audit data.
Optimizes processes and workflows to achieve successful quality outcomes and benefit maximization.
Leads the oversight and management of key performance indicators and monitors and tracks to independently identify over/under utilization patterns and/or deviation from expected results.
Develops and implements utilization targets and drives accountability to benchmark metrics for staff productivity and membership management
Oversees the onboarding, education, training, and ongoing monitoring of all Clinical Services & Operations staff, ensuring appropriate decision-making, application of criteria, documentation, and adherence to all regulatory requirements across all lines of business.
Oversees the recruiting, performance, development and mentoring of staff.
Ensures that team members are clinically competent and adequately trained to apply medical necessity criteria.
Provides leadership and support to managers and supervisors.
Ensures monitoring and tracking tools are in place to adequately link and assess production and quality driven work products and outcomes to individual performers.
Leads talent management activities to develop and cultivate future leaders.
Oversees the implementation of processes and systems to improve the efficiency and effectiveness of utilization management for inpatient services.
Develops effective relationships with key health systems to improve communication, efficiency and effectiveness of utilization review process including leading clinical meetings to facilitate relationship building and identifying opportunities to advance access to EMRs/Portals.
Serves as the subject matter expert liaison for acute and post-acute service and/or leader on cross-functional teams.
Initiates cross functional/departmental discussions and initiatives to remove barriers and improve communications and workflows.
Develops formal policies, procedures and workflows that effectively guide quality of work.
Performs other duties as assigned.

Benefits

Laptop, monitors, keyboard, mouse and headset provided.
Access to on-site fitness centers or gym membership reimbursement.
On-site cafeteria at Brooklyn, OH headquarters.
Discounts at many places.
Opportunity to earn cash rewards for shopping with customers.
Business casual attire, including jeans.
Employee bonus program.
401(k) with company match up to 4% and an additional company contribution.
Health Savings Account with a company matching contribution.
Excellent medical, dental, vision, life and disability insurance.
Access to an Employee Assistance Program.
Company holidays.
Up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
Parental leave for eligible employees who become parents through maternity, paternity or adoption (after 120 days of service).
Career development programs and classes.
Mentoring and coaching.
Tuition reimbursement up to $5,250 per year.
Diverse, inclusive and welcoming culture with Business Resource Groups.