Director of Utilization Management

3 weeks ago

Bakersfield, United States Kern Health Systems Full time

KHS reasonably expects to pay starting compensation for the position of Director of Utilization Management in the range of $153,597 - $199,676 annually.

Our Mission.. Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system.

About the role

The Director of Utilization Management (UM) provides comprehensive oversight of the Utilization Review process under the Knox Keene license and Department of Health Care Services contract. The position integrates and coordinates services using continuous quality improvement initiatives to promote positive member outcomes. Frequent executive level reporting and tracking on department and individual team productivity is essential. The Director of UM assesses needs, plans, communicates, designs services and strategies to forward the mission and serve member needs. The Director provides strategic leadership, development, and supervision to utilization review department, provides inter-professional collaboration with facility-based case managers and discharge planners, and coordinates with all aspects of the Kern Health Systems functions, including Claims and Member Service, to provide guidance on complex Authorizations, Referrals, Denials and Appeals.

Under the direction of the Utilization Management Medical Director, and in collaboration with the Chief Medical Officer, Sr. Director of Health Services, and the Director of UM assists in coordinating clinical functions and programs which effectuate and support KHS medical policy according to contractual requirements, and in developing and implementing new clinical programs to manage costs and ensure quality care delivery. The position will be an essential contributor to the development, implementation, and monitoring of the medical management strategy and ongoing process improvement.

Essential

**Responsibilities**:

- Oversees formal utilization and network coordination services. Provides operational oversight and recommends corrective action for all shared services
- Manages the UM results, including referral management; acute, SNF and Rehab admissions
- Continually creates and implements strategies to improve organizational and UM Departments performance
- Participates in contracted provider network meetings to enhance communication and continuity of member care services
- Has management responsibility as assigned for the key Medical Management Programs, Coordinated Care, DME, Ancillary services, and Pharmaceutical collaboration
- Participates in determination of department’s goals and objectives, setting organizational structure, staffing, and space planning
- Participates in recruitment, retention, and training of UM Management staff.
- Acts as a resource to other departments in regard to Case Management, Disease Management,

Health Education, Quality Improvement, Compliance, Provider Network Management, and Claims
- Collaborates with Executive leadership of Medical Management, Medical Directors, UM Management, and other staff as well as other departmental peers
- Program Development, Implementation and Evaluation
- Conduct needs assessment including development of methods for determining potential patient enrollment, medical literature review, analysis of pre-program utilization and return on investment
- Development and Implementation of the UM Program to include establishment of policies and procedures, enrollment strategies, member and physician materials, and measurements of program outcome
- Evaluate staff educational needs and coordinate training
- Analytical ability for problem identification and assessment and evaluation of data/statistics obtained from an on-going review process.
- Knowledge of Milliman Care Guidelines (MCG), InterQual Criteria, MCAL and CMS Criteria
- Knowledge of managed care health plans operations and HIPAA guidelines
- Experience and knowledge in intermediate computer skills (i.e. Microsoft Word, Excel)
- Leads and participates in cross functional corporate teams which design and implement new population management programs
- Develops and implements process and program redesigns.
- Leads multiple teams of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources.
- Ability to utilize multiple technology systems for documentation and coordination of services.
- Ensures adherence to all contract, regulatory and accreditation requirements.
- Develops short/long-term objectives and monitors processes and procedures to ensure consistency with the enterprise and compliance with state and federal regulations.
- Collaborates with community partners to resolve issues or find solutions.
- Manages budget and special projects.
- Hires, trains, coaches, counsels, and evaluates performance of direct reports.
- Serves in a supportive role as a member of the Physician’s Advisory, Quality Improvement and Utilization Management, Compliance, Fraud, Was

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