Director, Utilization Management

4 weeks ago

Washington, United States ASSOCIATION FOR COMMUNITY AFFILIATED PLANS Full time

Morgan Consulting Resources, Inc. has been retained to conduct the search for an experienced

Director, Utilization Management (Medicaid)

with

Sentara Health Plans in Virginia . This is a remote position with some travel to Richmond and Virginia Beach, VA. About the Organization: Sentara Health Plans is the health insurance division of Sentara Health. Sentara Health Plans provides health insurance coverage through a full suite of commercial products including consumer-driven, employee-owned and employer sponsored plans, individual and family health plans, employee assistance plans, and plans serving Medicare and Medicaid enrollees. With more than 30 years’ experience in the insurance business and 20 years’ experience serving Medicaid populations, Sentara offers programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services – all to help members improve their health. Learn more at Sentara.com. About the Position: Reporting to the Vice President, Medicaid Clinical Care Services, the Director of Utilization Management (UM) Medicaid is responsible for providing oversight to the daily functions of the UM staff and monitoring staff performance in accordance with Health Plan policies and procedures. Responsible for assessment, planning, implementation, coordination, monitoring, and evaluation of the managed care members’ performance across the continuum of care to include the complete transition of care to outpatient care. We are looking for a strong UM leader with MCO experience with a strategic mindset and strong business acumen. The successful candidate will be a collaborative, highly motivated leader with a deep understanding of health plan managed care UM. Responsibilities: Leads special projects, reviews of Medicaid UM programs, and evaluation of Medicaid UM performance, as indicated by contract, regulatory, and/or accreditation requirements. Collects, analyzes, audits, and reports Medicaid UM program trends and quality outcomes Provides clinical and operational oversight of each UM initiative which includes analysis of clinical data to drive performance improvement. Develops, implements, and monitors policies and procedures for contract and accreditation compliance. Provides recommendations to senior leaders on healthcare strategies, product development, policy and procedure changes and/or cost control opportunities. Ensures appropriate operational and system efficiencies are core to the utilization management process including continuous process improvement strategies. Qualifications: Single state RN (based on remote state) required 5+ years of nursing experience5+ years of experience in a managed care setting; preference for health plan experience of utilization management 5+ years’ leadership experience Microsoft Word & Excel UM Monitoring Project Management & Time Management Quality Control Analysis Service Orientation Systems Analysis & Evaluation Critical Thinking & Complex Problem Solving Judgment & Decision Making Persuasion & Leadership Through Change Management of Financial, Material & Staff Resources Candidates must have residency in one of the following states to work remotely in this position:

Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington (state), West Virginia, Wisconsin, Wyoming. To further explore this opportunity, express interest, or share referrals, please contact Amy Jones: Amy Jones, Senior Executive Search Consultant Morgan Consulting Resources, Inc. ~ Healthcare Executive Search amy@morganconsulting.com

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