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Utilization Management Program Director

2 months ago

Acton, California, United States CMP Full time
Job Summary:
As a key member of the CMP team, the Utilization Management Program Director will oversee the day-to-day operations of the Utilization Management Program in the Service Area or a Medical Center. This role requires a strong focus on delivering cost-effective and quality patient care by optimizing resource utilization. The ideal candidate will provide direction to staff, ensuring seamless coordination of care across the continuum.

Key Responsibilities:
  • Develop and maintain policies and procedures for the Service Area or Medical Center related to Utilization Management, ensuring compliance with regulatory agencies and internal standards.
  • Collaborate with multi-disciplinary teams to plan and coordinate care, identifying risk management and quality of care issues across the continuum.
  • Manage member care with non-KFH hospital facilities and providers, ensuring alignment with Health Plan guidelines and patient needs.
  • Surface issues and suggestions to the appropriate multi-disciplinary team members, promoting a culture of continuous improvement.
  • Oversee the transportation program, ensuring optimal resource utilization and adherence to Health Plan guidelines.
  • Ensure compliance with Federal, State, TJC, NCQA, and other regulatory agencies' requirements, as well as internal standards and requirements.
  • Provide direction to staff regarding utilization review, care coordination, discharge planning, and other services across the continuum of care.
  • Conduct statistical studies on utilization trends, patterns, and outcomes, informing data-driven decision-making.
  • Hire, train, coach, discipline professional and clerical support staff, fostering a high-performing team.
Requirements:
  • Minimum three (3) years of experience in utilization management and discharge planning in an acute care setting, with supervisory or management experience.
  • BSN or bachelor's degree in a healthcare-related field, such as management or health services administration.
  • Registered Nurse License (California).
Additional Skills:
  • Demonstrated knowledge of operations and healthcare management, including TJC, Title XXII, Medicare, MediCal, and other local, state, and federal regulations.
  • Knowledge of managed care operations and ability to work in a Labor/Management Partnership environment.
  • Excellent interpersonal, negotiation, and management skills, with good oral and written communication skills.