Director of Utilization Management and Operations

3 weeks ago


Étreux, Hauts-de-France, United States Commonwealth Care Alliance Inc. Full time

The Director of Utilization Management and Operations at Commonwealth Care Alliance Inc. leads and manages all utilization management functions for physical health services and long-term services and supports. This role is responsible for setting strategic direction, planning, budgeting, policy development, and business process management and improvement for all UM functions. The Director works closely with the Chief Medical Officer and Vice President of Medical Affairs to develop and advance the UM program, collaborates with the Behavioral Health UM team, multiple clinical groups, and provider partners in care management and care delivery, oversees the delegated entity UM functions, and supports initiatives with providers and members to ensure the appropriate utilization of services.

Key Responsibilities:

  • Directs, coordinates, and evaluates the efficiency and productivity of utilization management functions for physical health services and long-term services and supports.
  • Ensures compliance with all contract requirements, state and federal regulatory requirements, and all applicable accreditation standards.
  • Develops and implements strategies to improve the quality and efficiency of utilization management processes.
  • Collaborates with the CMO and VPMA to develop and advance the UM program.
  • Leads and organizes the ongoing evaluation of the utilization management program against quality and utilization benchmarks and targets.
  • Identifies opportunities for improvement and organizes and manages outcome improvement initiatives.
  • Ensures staff selection, training, and performance monitoring.
  • Leads the Utilization Management team in managing and continuously improving UM program design, policies, procedures, workflows, and correspondence.
  • Supports provider relations and provider contracting leaders in the design and implementation of successful methods for working with providers.
  • Directs the work of the utilization management team to ensure quality, interrater reliability, and standards are met in daily operations.
  • Provides expert input to Finance regarding patterns of utilization and cost and high-cost cases.

Requirements:

  • Bachelor's Degree or equivalent experience.
  • Active RN license required.
  • 7-10 years of managed care operations experience, including a minimum of five (5) years of leadership experience in Utilization Management (UM) or nursing leadership.
  • Minimum three (3) years of management experience in a health plan environment with responsibility for managing the effective utilization of healthcare services, case/disease management, program development/management/evaluation, and quality improvement.
  • Minimum five (5) years of clinical experience in medical or behavioral health care delivery.

Preferred Qualifications:

  • Master's degree in Business or Health related field.
  • Medicare and Medicaid managed care experience.
  • Demonstrated knowledge of federal and state regulations relevant to utilization management.
  • Demonstrated knowledge of health care industry trends, developments, and issues.


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