Utilization Management Director
1 month ago
We are seeking a highly skilled Utilization Management Director to join our team at APLA Health. As a key member of our healthcare operations team, you will be responsible for managing the daily operations of Utilization Management (UM) at APLA Health and Wellness (APLAHW).
Key Responsibilities- Develop and implement a standardized Utilization Management Program to ensure compliance with internal, government, health plan/IPA, and medical group requirements.
- Ensure staff competency through inter-rater reliability tools and evidence-based criteria for utilization review.
- Develop, implement, and maintain compliance, policies, and procedures regarding medical utilization management functions.
- Establish and maintain excellent working relationships with internal and external constituents, including the Chief Medical Officer, clinic directors, and site medical directors.
- Participate in the collection, analysis, and reporting of data relevant to utilization management.
- Collaborate with the Quality Director to identify opportunities for process improvements in Utilization Management that align with the organization's vision and strategic long-term goals.
- Develop, implement, and maintain utilization management programs to facilitate the use of appropriate medical resources and minimize financial exposure.
- Compile and review reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management.
- Communicate with staff to convey health plan, contract, or operations information to ensure a consistent and appropriate knowledge base for performing duties.
- Promote staff growth and development by identifying educational opportunities to increase efficiency and maintain compliance with industry standards.
- Supervise a team of referral coordinators, patient engagement and retention specialists, and medical records coordinators.
- Optimize processes and workflows for the UM staff.
- Ensure referrals staff meet key quality and risk management goals and referrals are properly tracked.
- Hire and train new UM staff as needed.
- Manage the medical group's referral filter tool and flag questionable referrals for further evaluation by the site medical director.
- Supervise staff monitoring patients in emergency departments and hospitals in real-time and ensure patients receive appropriate follow-up by clinical staff.
- Ensure high-utilizing patients are appropriately engaged in case management programs.
- Report key UM metrics at monthly agency quality meetings.
- Lead monthly UM committee meetings.
- Five years' utilization/care management experience in a clinical or managed care setting preferred.
- Four years' management/supervisory experience (in a formal or informal role) preferred.
- Requires a Bachelor's degree in Nursing (RN with active California certification) or other healthcare-related field like MPH, MHA, MBA/MS in healthcare-related field.
- Basic computer skills in a Windows operating environment, including Microsoft Word, Excel, and an email system.
- Must be a dynamic leader, able to navigate a complex environment, with excellent verbal and written communication skills, as well as strong operations experience.
- Effective influencing, negotiation, relationship-building, and communication skills are essential.
- Effective employee management skills.
- Possess strong leadership, critical-thinking, and motivational skills/abilities.
- Excellent problem-solving and organizational skills required.
- Knowledge of InterQual and/or Milliman software preferred.
- Knowledge of electronic health records systems (eClinicalWorks preferred).
- Knowledge of ambulatory healthcare delivery and management.
- Knowledge of NCQA, DMHC, CMS, and other regulatory agency requirements pertaining to delivery of healthcare in the managed care setting.
This is primarily an office position that requires occasional bending, reaching, stooping, lifting, and moving of office materials weighing 25 pounds or less. The position requires daily use of a personal computer and requires entering, viewing, and revising text and graphics on the computer terminal and on paper.
Special RequirementsMust possess a valid California driver's license; proof of auto liability insurance; and have the use of a personal vehicle for work-related purposes. COVID Vaccination and Booster required or Medical/Religious Exemption.
Equal Opportunity Employer: minority/female/transgender/disability/veteran.
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