Utilization Management Director
5 days ago
CareFirst BlueCross BlueShield is seeking a highly experienced and skilled Utilization Management Director to lead our clinical operations team. As a key member of our leadership team, you will be responsible for developing and implementing strategic plans to enhance member engagement, improve access to quality care, and optimize the use of cost-effective health resources.
Key Responsibilities- Provide strategic leadership to the utilization management team, ensuring alignment with CareFirst's business strategy and regulatory requirements.
- Develop and implement utilization management strategies, including the design, assessment, and implementation of programs to enhance member engagement and improve access to quality care.
- Collaborate with leadership, members, providers, vendors, and other stakeholders to ensure seamless coordination and communication.
- Oversee the negotiation of access to care in targeted areas, maintaining relationships with providers and pursuing a responsive system for authorization of services and approved claims.
- Ensure compliance with policies, including safety, infection control, regulatory, and accreditation requirements, and quality assurance.
- Direct staff, assign work, review, and evaluate hiring methods to meet departmental needs.
- Develop and monitor budgets for programs, reporting performance measurements and making recommendations for continuous improvement.
- Bachelor's Degree in Nursing or equivalent experience.
- 8 years of experience in a clinical and utilization review role, with 3 years of management experience.
- Knowledge of Medicare Advantage, Medicaid Managed Care, and utilization management processes, standards, and managed care.
- Proficient in standard medical practices and insurance benefit structures.
- Ability to mentor and coach associates, provide objective evaluation of associate performance, and implement strategies to improve individual and team-based performance.
CareFirst BlueCross BlueShield offers a comprehensive benefits package, various incentive programs, and 401k contribution programs. We are an Equal Opportunity Employer and welcome applications from diverse candidates.
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