Director, Utilization Management
About The Position
Directs the utilization management team to ensure the appropriate application of policy procedures and processes to help support best member outcomes. Oversees and manages Utilization Operations specific to the daily operations of Utilization Management including timeliness, quality and performance outcomes, provider interactions and experience and associated regulatory and/or compliance measures. Applicants must reside in Florida. The ideal candidate will have leadership experience and a strong background in Long-Term Care (LTC) Utilization Management, including Medicaid managed care, LTSS/LTC, prior authorization, and care management operations.
Requirements
- Bachelor's degree and 7+ years of related experience, including prior management experience.
- Or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position.
- Must reside in Florida.
Nice To Haves
- 4+ years management experience preferred.
- Expert knowledge of industry regulations, policies, and standards preferred.
- RN - Registered Nurse - State Licensure and/or Compact State Licensure preferred
- Strong background in Long-Term Care (LTC) Utilization Management, including Medicaid managed care, LTSS/LTC, prior authorization, and care management operations.
Responsibilities
- Leads utilization management team on performance, improvement, and career growth path considerations
- Leads utilization management team policies and procedures to ensure compliance with corporate, state, and National Committee for Quality Assurance (NCQA) standards
- Reviews, analyzes, and reports on utilization trends, patterns, and impacts to deliver an effective utilization program
- Leads process improvements for the utilization management team to achieve cost-effective healthcare results and presents to senior leadership team
- Establishes policies and procedures that incorporate best practices and ensure effective utilization reviews of members
- Develops utilization management strategies and influences decisions by providing recommendations that align to organizational objectives
- Responsible for components of the department’s budget while collaborating inter-departmentally with senior leadership
- Executes the overall strategy for onboarding, hiring, and training new utilization management team members to ensure adequate training and high quality-care to improve member and provider experience and ensure compliance
- Leads and manages others in a matrixed/cross functional environment with tight timeframes and strict deadlines
- Leads and champions change within scope of responsibility
- Performs other duties as assigned
- Complies with all policies and standards
Benefits
- competitive pay
- health insurance
- 401K
- stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- flexible approach to work with remote, hybrid, field or office work schedules
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What This Job Offers
Job Type
Full-time
Career Level
Director
