Senior Director of Utilization Management

MiraVista Behavioral Health Center•Holyoke, MA

5d•Onsite

About The Position

Reporting to the Chief Financial Officer, the Senior Director of Utilization Management will oversee the comprehensive UM strategy, ensuring The Vista Hospitals meet all state, federal, and regulatory requirements. The Senior Director will work across departments to ensure seamless coordination and operational workflows. The Senior Director of Utilization Management Provides leadership in the development, direction and evaluation of an effective utilization management program that supports the delivery of high-quality health care in the most appropriate and cost-effective manner. Provides consultation and support for Providers and Clinical Staff utilization review activities that influence medical and clinical outcomes. The Senior Director of Utilization Management is responsible for planning, organizing, developing, and directing implementation of the hospital's Utilization Review Plan and the overall operation of the Utilization Management Department in accordance with federal, state and local guidelines, regulatory agencies, and hospital contractual payor agreements. Utilization Management is responsible for the quality, effectiveness, and efficiency of utilization review processes inclusive of prior authorization, concurrent and respective review, transitions of care, readmission reduction, hospital resource utilization and payer denial mitigation. This position works with hospital leadership to coordinate and integrate utilization management activities, using continuous quality improvement initiatives to promote positive patient outcomes. Coordinates data collection and reporting to verify outcomes, effectiveness of utilization management activities and appropriate use of resources, to achieve appropriate length of stay and level of care, while promoting cost effective and quality patient care. As the Senior Director of Utilization Management: Partners with all Hospitals and service area leadership as well as health care teams to ensure that required internal systems and processes to manage the high risk, high cost of care needs are delivered effectively and that they are supported, monitored and evaluated on an ongoing basis, and follow CMS Guidelines. Leadership acumen directing teams in both Inpatient and Outpatient systems, including change management efforts. Ability to work in and with an intricate system of care and decision making. Develops systems to ensure effective coordination and integration between Utilization Management functions and Clinical Review, Contracting, and Claims Processes. Works collaboratively with other key Hospital leaders to ensure that the processes exist that will result in benefits that are delivered and paid appropriately in accordance with contractual provisions and in the best interest of the patient. Represents the Hospital system in utilization management in regulatory, licensing and legislative arenas, such as CMS, State or other employer requirements. Prepares and presents information and testimony to ensure compliance with medical guidelines and procedures required by both KP internally and/or outside accredited agencies. Accountable for the administrative leadership and budgetary responsibility for the team of staff that support these functions in the department. Ensures that their functions are aligned with and supportive of the overall operational leadership goals. Ensures the quality oversight of contracted and internal services in the continuum of care. Collaborates with member appeals. Manages regulatory turn around for processing referrals and/or denials or appeals with relevant parties.

Requirements

Bachelor's Degree in Health Care Administration, Nursing, Business or related field required.
Minimum ten (10) years of multi-faceted health care system management experience with at least five (5) years within a health plan setting.
Thorough knowledge of utilization review.
Track record achieving superior results that demonstrate performance improvement and quality and service outcomes.

Nice To Haves

Master's degree in health care administration, Nursing, Business or related field preferred.
Clinical license such as RN preferred but not required.
Case Management experience preferred but not required.

Responsibilities

Oversee the comprehensive UM strategy, ensuring The Vista Hospitals meet all state, federal, and regulatory requirements.
Work across departments to ensure seamless coordination and operational workflows.
Provide leadership in the development, direction and evaluation of an effective utilization management program that supports the delivery of high-quality health care in the most appropriate and cost-effective manner.
Provide consultation and support for Providers and Clinical Staff utilization review activities that influence medical and clinical outcomes.
Plan, organize, develop, and direct implementation of the hospital's Utilization Review Plan and the overall operation of the Utilization Management Department in accordance with federal, state and local guidelines, regulatory agencies, and hospital contractual payor agreements.
Ensure the quality, effectiveness, and efficiency of utilization review processes inclusive of prior authorization, concurrent and respective review, transitions of care, readmission reduction, hospital resource utilization and payer denial mitigation.
Coordinate and integrate utilization management activities with hospital leadership, using continuous quality improvement initiatives to promote positive patient outcomes.
Coordinate data collection and reporting to verify outcomes, effectiveness of utilization management activities and appropriate use of resources, to achieve appropriate length of stay and level of care, while promoting cost effective and quality patient care.
Partner with all Hospitals and service area leadership as well as health care teams to ensure that required internal systems and processes to manage the high risk, high cost of care needs are delivered effectively and that they are supported, monitored and evaluated on an ongoing basis, and follow CMS Guidelines.
Direct teams in both Inpatient and Outpatient systems, including change management efforts.
Develop systems to ensure effective coordination and integration between Utilization Management functions and Clinical Review, Contracting, and Claims Processes.
Collaborate with other key Hospital leaders to ensure that the processes exist that will result in benefits that are delivered and paid appropriately in accordance with contractual provisions and in the best interest of the patient.
Represent the Hospital system in utilization management in regulatory, licensing and legislative arenas, such as CMS, State or other employer requirements.
Prepare and present information and testimony to ensure compliance with medical guidelines and procedures required by both KP internally and/or outside accredited agencies.
Provide administrative leadership and budgetary responsibility for the team of staff that support these functions in the department.
Ensure that their functions are aligned with and supportive of the overall operational leadership goals.
Ensure the quality oversight of contracted and internal services in the continuum of care.
Collaborate with member appeals.
Manage regulatory turn around for processing referrals and/or denials or appeals with relevant parties.