Chief of Utilization Oversight

1 week ago

Bakersfield, California, United States Impresiv Health Full time
Position: Director of Utilization Management

Employment Type: Direct Placement

Location: Bakersfield, CA

Overview:
The Director of Utilization Management (UM) is responsible for the comprehensive administration of the Utilization Review process. This role involves the integration and coordination of services through continuous quality improvement initiatives aimed at enhancing member outcomes. Regular executive-level reporting and monitoring of departmental and individual team productivity are crucial. The Director of UM evaluates needs, communicates effectively, and designs services and strategies to advance the mission and meet member requirements. This position provides strategic leadership, development, and oversight to the utilization review department, fostering inter-professional collaboration with facility-based case managers and discharge planners while coordinating with all aspects of Kern Health Systems functions, including Claims and Member Services, to offer guidance on complex Authorizations, Referrals, Denials, and Appeals.

Under the guidance of the Utilization Management Medical Director, and in partnership with the Chief Medical Officer and Sr. Director of Health Services, the Director of UM plays a pivotal role in coordinating clinical functions and programs that support client medical policy in accordance with contractual obligations, as well as in the development and implementation of new clinical programs aimed at managing costs and ensuring quality care delivery. This position is a key contributor to the formulation, execution, and monitoring of the medical management strategy and ongoing process enhancements.

Key Responsibilities:
  • Oversee formal utilization and network coordination services, providing operational guidance and recommending corrective actions for shared services.
  • Manage UM outcomes, including referral management and admissions for acute, SNF, and Rehab.
  • Continuously develop and implement strategies to enhance organizational and UM Department performance.
  • Engage in contracted provider network meetings to improve communication and continuity of member care services.
  • Hold management responsibility for key Medical Management Programs, including Coordinated Care, DME, Ancillary services, and Pharmaceutical collaboration.
  • Contribute to the establishment of departmental goals and objectives, organizational structure, staffing, and space planning.
  • Participate in the recruitment, retention, and training of UM Management personnel.
  • Act as a resource for other departments regarding Case Management, Disease Management, Health Education, Quality Improvement, Compliance, Provider Network Management, and Claims.
  • Collaborate with Executive leadership in Medical Management, Medical Directors, UM Management, and other staff as well as departmental peers.
  • Engage in Program Development, Implementation, and Evaluation.
  • Conduct needs assessments, including methods for determining potential patient enrollment and analyzing pre-program utilization and return on investment.
  • Develop and implement the UM Program, establishing policies and procedures, enrollment strategies, member and physician materials, and outcome measurements.
  • Evaluate staff educational needs and coordinate training initiatives.
  • Utilize analytical skills for problem identification and assessment, evaluating data/statistics from ongoing reviews.
  • Possess knowledge of Milliman Care Guidelines (MCG), InterQual Criteria, MCAL, and CMS Criteria.
  • Understand managed care health plan operations and HIPAA regulations.
  • Demonstrate proficiency in intermediate computer skills (e.g., Microsoft Word, Excel).
  • Lead and participate in cross-functional corporate teams to design and implement new population management programs.
  • Develop and execute process and program redesigns.
  • Lead multiple clinical teams focused on promoting quality member outcomes and optimizing resource utilization.
  • Utilize various technology systems for documentation and service coordination.
  • Ensure compliance with all contract, regulatory, and accreditation standards.
  • Establish short and long-term objectives, monitoring processes to ensure alignment with enterprise goals and compliance with state and federal regulations.
  • Collaborate with community partners to address issues and develop solutions.
  • Manage budgetary responsibilities and special projects.
  • Recruit, train, coach, counsel, and evaluate the performance of direct reports.
  • Participate as a member of various committees focused on quality improvement and compliance.
  • Conduct detailed utilization analysis and benchmarking.
  • Encourage staff development through growth opportunities and training sessions.
  • Direct and assess the efficiency and productivity of utilization management functions for both physical and behavioral health services.
  • Establish a comprehensive orientation program for new UM Department employees.
  • Monitor after-hours clinical triage programs to assist members in accessing appropriate medical care outside standard office hours.
  • Collaborate with network leaders to design effective methods for engaging with hospitals, home health, and ancillary services.
  • Assist in reviewing and updating Policies and Procedures.
  • Coordinate with Health Services leadership to identify inappropriate service utilization.
  • Work with Provider Network Management on referral and inpatient activities requiring provider feedback.
  • Review and approve Notice of Action (NOA) letters and Letters of Agreement (LOA) for non-contracted providers and facilities.
  • Evaluate and initiate processes towards NCQA accreditation in Utilization Management.
  • Conduct interviews, select, train, develop, and evaluate staff; provide input on disciplinary matters.
  • Perform additional job-related duties as necessary.
  • Adhere to all company policies and procedures related to employment and job responsibilities.

Qualifications:
  • Bachelor's degree (BSN) from an accredited institution in Nursing or a relevant healthcare field is required; a Master's degree (MSN) is preferred.
  • Possession of a current, active, and unrestricted RN license for the state of California.
  • A minimum of five (5) years of management-level experience in Utilization Management within a managed care environment or healthcare industry.
  • At least five (5) years of clinical experience in Utilization Review or Case Management in a Health Plan or similar setting.
  • Experience with Utilization Management in a managed care context, including claims processing procedures and medical reimbursement methodologies.
  • Knowledge of regulations and requirements related to utilization management (UM) and experience with QA/QI and program development/process improvement.
  • Possession of a valid driver's license and proof of state-required auto liability insurance; travel may be required.
  • Bilingual (English/Spanish) is preferred.
  • Ability to adapt to a rapidly changing work environment, manage multiple responsibilities, and communicate effectively with diverse personnel.

About Impresiv Health:

Impresiv Health is a healthcare consulting partner specializing in clinical and operational management, enterprise project management, professional services, and software consulting. We assist our clients in enhancing operational efficiency by delivering innovative solutions to address their most complex business challenges. Our approach is straightforward: we prioritize understanding and acting in the best interest of our clients, delivering tangible results that add immediate value at competitive rates. Your success is our priority, and we are committed to supporting you.

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