Utilization Management Director Jobs

About The Position

Requirements

• Bachelor’s degree in Nursing required.
• Minimum five (5) years of clinical experience.
• Three (3) years of managed care (utilization or case management) experience.
• Minimum three (3) years of management experience in a medical management setting, with effective problem solving in an area where few precedents have been set.
• Current California Registered Nurse license.
• Effective telephone and computer skills required.
• Working knowledge and experience with ICDCM and CPT coding schemes.
• Thorough knowledge of utilization and case management programs and application of related clinical criteria and protocols.
• Ability to work effectively across departments and functions within the organization.
• Competency with PCs and medical management software, word processing, spreadsheets, etc.
• Valid California driver’s license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business.

Nice To Haves

• Knowledge of and experience with Federal Medicaid and/or California Medi-Cal programs preferred.

Responsibilities

• Provides day-to-day direction to Utilization Managers and Supervisors to meet department goals and objectives.
• Responsible for ensuring performance evaluations are completed appropriately in a timely manner.
• Participates in the grievance process.
• Coordinates activities with Member Services, Claims, and Provider Relations departments to identify, track, and monitor quality of care issues and trends.
• Responsible for establishing and maintaining reports that will support the efficacy of each Utilization Management (UM) activity and to produce a summary at least annually or upon request that includes statistical reports of activity, quality improvement activities, and utilization outcomes.
• Provides oversight and monitoring of the medical claims review and appeals to ensure timely accurate response.
• Provides direction and oversight to ensure efficient and appropriate collaboration between the Utilization Management staff and the delegated mental health provider and other internal and external organizations.
• Ensures that all policies and procedures are updated at least annually or as needed and presented to appropriate committees for review.
• Participates in annual delegation audits for UM, prepares report for presentation to Director of Utilization Management and responsible Committees.
• Works with all other departments to resolve claims, UM, QI, and member issues as necessary.
• Reports any issues with regulatory compliance to Director of Utilization Management and assists in design and implementation of a corrective action plan as necessary.
• Prepares reports on departmental activities according to established schedules and format. Identifies patterns and trends and works with Managers to develop corrective action plans.
• Works with Managers, Supervisors, and Trainer to develop standardized training content and material for new staff and for the ongoing education of existing staff.
• Provides oversight of training program to ensure adequate training accomplishes objectives and results in staff competency.
• Conducts retrospective review, either in the aggregate or on an individual basis, as needed. Provides summaries of findings to the Director of Utilization Management as requested.
• Assists Partnership staff and providers with the interpretation of Partnership policies, procedures, and regulatory requirements for all product lines.
• Promotes the continuous improvement process and implements recommended changes.
• Participates in all cost containment efforts of both the Health Services department and Partnership.
• Develops annual goals for individual performance and updates at least every six (6) months for progress.
• Works with other departments within Partnership to develop and implement improvements that will lead to improved performance or enhanced workflow of staff.
• Participates in the planning of new enhanced Health Services products.
• Participates in onsite audits by various regulatory agencies as necessary.
• Leads, assigns, and participates in special projects and assignments as required.

Benefits

• Provide the highest possible level of service to clients
• Promote teamwork and cooperative effort among employees
• Maintain safe practices
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.