Current jobs related to Director, UM - Dover - Evolent Health

Evolent Health - Director, UM - Dover, Delaware

Evolent partners with health plans and providers to achieve better outcomes for people with the most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of the fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. What You’ll Be Doing: As a Director, Utilization Management, you’ll work with your managers, front line clinical team, and matrix partners to ensure delivery on clinical excellence, performance guarantees, and efficiencies for our members, providers, and customers. The Director, Utilization Management, will partner with a variety of different departments, including but not limited to, Medical Leaders, Partner Operations, Quality/Compliance, Implementations. What You Will Be Doing: Leadership of utilization management (UM) activities including design, implementation, and oversight of the operations. Operational activities include clinical review of prior authorization requests and support additional features such as training, appeals, and grievances for clients who have delegated UM. Monitor all activities related to clinical review. Develop processes where indicated with direct oversight of centralized telephonic review process of all necessary utilization management components. Partner with leadership to mentor staff. Jointly develop goals, objectives and define major roles. Implement processes, procedures and accountabilities for staff. Responsible for achieving targeted utilization management results established by the department and/or client by monitoring and reporting the utilization management resources, implementing initiatives and educational processes. Develop and adopt best practice methodologies and training programs for utilization management tools and techniques. Provide recommendations on staffing plans, and assuring adequate allocation of resources for UM functions, and coordinating needs with market clinical leadership. Collaborate with IT and Analytics teams for the development of required utilization management monitoring, initiatives, patient engagement and other outcomes initiatives. Collaborate with other functional areas that interface with the utilization management department, including but not limited to claims, appeals, product, network development and care management. Provide appropriate and timely management of complex clinical issues. Mentor and support ongoing training and development of staff. Promote a positive work environment by providing timely, specific and constructive performance feedback. All other duties as assigned. Qualifications - Required and Preferred: Active clinical license such as Registered Nurse (RN), Physical/Occupational/Speech/Radiation Therapist or Chiro, Pharmacist -

Required Working knowledge of utilization management activities such as prior authorization, concurrent review, intake, appeals and grievances -

Required Five (5) to seven (7) years of progressive experience in utilization management -

Required Bachelor’s Degree in Nursing or related healthcare field (with Bachelor’s/Master’s Degree in Business Administration/Hospital Administration/Public Health) -

Preferred Technical Requirements: We require that all employees have the following technical capability at their home: High-speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations. Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.

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