Director Utilization Management

UMass Memorial Health-posted about 1 year ago
Full-time • Senior
Worcester, MA
10,001+ employees
Ambulatory Health Care Services
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The Director of Utilization Management at UMass Memorial Health Care is responsible for overseeing the utilization management staff and processes, ensuring compliance with regulatory requirements, and optimizing clinical and financial outcomes. This role involves designing work processes, setting performance goals, integrating technology, and fostering relationships with various stakeholders to enhance patient care and staff satisfaction.

  • Designs work processes and assignments for utilization management staff, including level of care assignment and denials prevention.
  • Identifies objectives and creates performance goals to evaluate the performance of utilization management staff and the program.
  • Integrates innovative technology into the utilization management process to improve effectiveness and enhance satisfaction and outcomes.
  • Promotes integration of clinical guidelines, performance improvement initiatives, and patient satisfaction efforts into the utilization management program.
  • Ensures compliance with regulatory and reporting requirements and maintains awareness of changing requirements.
  • Develops and maintains good relationships with Physician Advisors, care coordination, clinical denials, and care teams.
  • Assures integration of utilization management operations with internal revenue cycle systems and third-party payer systems.
  • Bachelor's degree in nursing, healthcare, program management, MBA, finance, social work, public health, or another related field.
  • Current Massachusetts RN license and registration.
  • Five years managing teams or projects in a healthcare environment.
  • Five years of Case/Utilization Management experience.
  • Five years of conducting and managing Utilization Reviews using InterQual Criteria.
  • Five years of creating and managing workflows and processes and developing and managing departmental budgets experience.
  • Five years of analyzing healthcare utilization data, implementing metrics, and ensuring efficiency.
  • Five years of operating in a union environment.
  • Five years of planning, organizing, and evaluating programs.
  • Five years of developing policy, including cross-functional collaboration.
  • Five years of presenting utilization data to executive leadership.
  • Proficiency in common computer applications like Microsoft Word, Excel, PowerPoint, Outlook, and basic computer functions.
  • Demonstrated excellence in written and oral communication.
  • Master's degree in nursing, healthcare, program management, MBA, finance, social work, public health, or another related field.
  • Certified Case Manager (CCM).
  • Certified Professional in Healthcare Quality (CPHQ).
  • Certified Utilization Review Specialist (CURS).
  • Five years of experience in a clinical setting, such as nursing, case management, or social work.
  • Signing bonus eligibility (to be confirmed during the interview process).
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