Director of Utilization Management

7 days ago

Miami, United States Public Health Trust of Dade Co Full time
Job Title: Director of Utilization Management

At the Public Health Trust of Dade Co, we are seeking a highly skilled and experienced Director of Utilization Management to lead our utilization management strategy and provide management oversight in implementing, directing, and monitoring the escalation, conversions, LOC reviews, and other related activities.

Key Responsibilities:
  • Develop and implement a utilization management strategy that leverages data analytics and technology solutions to streamline operational efficiencies.
  • Build a cost-benefit methodology to rationalize decisions on utilization reviews based on staffing costs, productivity, and projected medical cost savings.
  • Identify opportunities to create efficiencies in the utilization management program and activities, incorporating innovative approaches and solutions, and leading process redesign work necessary to implement improvements.
  • Direct the utilization management, concurrent review, and functions.
  • Provide leadership in the design and implementation of utilization management policies, processes, and procedures needed to meet National Commission on Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC) accreditation requirements for both a Medi-Cal and Medicare line of business (D-SNP).
  • Establish and measure productivity metrics to support workforce planning methodology and rationalization of services to perform utilization management reviews.
  • Review and report out on utilization review trending.
  • Ensure quality of services through utilization review, review of medical records, and provider education, while identifying training opportunities and trends.
  • Design, develop, implement, and maintain programs, policies, and procedures to meet regulatory, contractual, accreditation, and performance standards.
  • Maintain knowledge of regulatory and accreditation agencies and related requirements pertinent to case management and integrated behavioral health, such as Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), Department of Managed Health Care (DMHC).
  • Oversee utilization review preparations and responses to regulatory audits and the construction of corrective action plans.
  • Participate in regulatory audits related to all aspects of utilization management.
  • Track, analyze, and develop strategies to address outlier performance of utilization metrics and report on metrics at a regular cadence.
  • Participate in strategic planning and implementation of the utilization development's operational goals related to the growth and development of business operations.
  • Conduct complex research and analysis related to utilization management strategies.
  • Model and promote effective interdepartmental communication. Prepare narrative and statistical reports and make presentations.
  • Draft, recommend, and implement administrative policies and processes and procedures related to utilization management operations.
  • Monitor legislative and legal changes related to utilization management functions and ensure appropriate communication.
  • Review and assess overall department functions, core work, goals, and structure.
  • Develop and implement short- and long-term planning to achieve strategic objectives and complete an annual department assessment.
  • Oversee, coordinate, or participate in a variety of DPC.
  • Develop and manage department operations and budget.
  • Provide support to CMOs and CM directors. Collaborate with the Medical Director team on complex cases.
  • Direct, manage, and supervise department staff.
  • Ensure staff maintains up-to-date knowledge, skills, and abilities related to the administration of assigned responsibilities and functions.
  • Oversee and assist with objectives, priorities, assignments, tasks, and reviewing work products as needed.
  • Provide mentoring, coaching, and development and growth opportunities for staff and subordinate managers and supervisors.
  • Evaluate employee performance, provide feedback to staff, and counsel or discipline staff when performance issues arise.
  • Perform all other related job duties as assigned.
Requirements:
  • Generally requires 5 to 7 years of related experience. Management experience is required.
  • Bachelor's degree in Nursing is required.
  • Valid Florida RN license is required.

Jackson Health System is an equal opportunity employer and makes employment decisions without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, disability status, age, or any other status protected by law.

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