Regional Utilization Management Director

2 months ago

Aurora, United States HealthEcareers - Client Full time
Salary Range: $65.38/hour - $84.56/hour
$60.53 - $71.20
Job Summary:

Manages the overall, regionwide utilization management function ensuring the accurate and timely prior authorization of designated healthcare services. Oversees the concurrent, discharge planning and retrospective review activities for the Colorado region. Manages utilization review staff.



Essential Responsibilities:

  • Manages the administrative and operational functions of the regional utilization management department.
  • Responsible for the planning and decision-making related to utilization review.
  • Develops and implements departmental policies and procedures.
  • Develops, implements, and maintains utilization management programs to facilitate the use of appropriate medical resources by health plan members/patients.
  • Identifies and monitors services with potential for undesirable variation to ensure accurate and consistent application of benefits and clinical guidelines or criteria. Develops and reviews medical necessity criteria and utilization management practices including a formal process of monitoring and evaluating the necessity, appropriateness, efficiency, effectiveness, and safety of medical services to achieve favorable healthcare outcomes.
  • Reviews analyses of activities, costs, operations and forecast data to determine progress toward utilization management goals and objectives.
  • Compiles and reviews multiple reports for statistical and financial tracking to identify utilization trends and make recommendations to management and to ensure inter-rater reliability of staff performance.
  • Ensures compliance with national and state regulatory/accreditation requirements related to utilization management by partnering with other departments and facilitating workgroups in maintaining survey readiness to ensure that all annual requirements are met.
  • Engages in monthly/quarterly/annual/triennial internal and external utilization management audits and surveys and delegation oversight audits.
  • Manages and oversees the utilization review management training and education program for Utilization Review leaders and staff across the region.
  • Ensures post-course evaluation tools and other materials are developed.
  • Manages training and education schedules.
  • Manages case managers including hiring, training, performance evaluations and terminations.
  • Ensures tools and technology are created and improved to perform activities and ensure timely and appropriate documentation for accurate data capture and reporting.
  • Facilitates on-going communication and manages relationships among utilization management staff, internal providers care management peers and leaders, and external/contracted providers.
  • Manages performance and issues with internal and external representatives regarding Union Issues, as necessary.

Basic Qualifications:
Experience

  • Minimum three (3) years of experience in directing utilization management and discharge planning in an acute care setting.

Education

  • Bachelors degree in related field OR four (4) years of experience in a directly related field.
  • High School Diploma or General Education Development (GED) required

License, Certification, Registration

  • N/A


Additional Requirements:

  • Thorough knowledge of utilization management and clinical practice.
  • Familiarity with Medicare and Medicaid managed care practices and policies, CHIP and SCHIP.
  • Knowledge of regulatory/accreditation requirements (NCQA, DMHC, DHCS, CMS, Medi-Cal Plan Partners, Special Needs Plan (SNP)).


Preferred Qualifications:

  • Recent clinical experience in a hospital setting preferred.
  • Bachelors degree in nursing preferred.
  • Case Management Certification preferred.
  • CO RN license preferred.

  • Regional Utilization Management Director

    3 weeks ago

    Aurora, United States Kaiser Permanente Full time

    Salary Range: $65.38/hour - $84.56/hour $60.53 - $71.20 Job Summary: Manages the overall, regionwide utilization management function ensuring the accurate and timely prior authorization of designated healthcare services. Oversees the concurrent, discharge planning and retrospective review activities for the Colorado region. Manages utilization review...

  • Regional Utilization Management Director

    2 weeks ago

    Aurora, United States Kaiser Permanente Full time

    Salary Range: $65.38/hour - $84.56/hour $60.53 - $71.20 Job Summary: Manages the overall, regionwide utilization management function ensuring the accurate and timely prior authorization of designated healthcare services. Oversees the concurrent, discharge planning and retrospective review activities for the Colorado region. Manages utilization review...

  • Regional Utilization Management Director

    2 months ago

    Aurora, United States CareerBuilder Full time

    Salary Range: $65.38/hour - $84.56/hour $60.53 - $71.20 Job Summary: Manages the overall, regionwide utilization management function ensuring the accurate and timely prior authorization of designated healthcare services. Oversees the concurrent, discharge planning and retrospective review activities for the Colorado region. Manages utilization review staff....

  • Regional Director Facility Management

    1 month ago

    Aurora, CO, United States Rocky Mountain Region Full time

    This role requires at least three or more years experience as a Director of Nursing in long-term care. The Regional Director of Clinical Services directs the operations, programs and activities of the region to maintain the highest quality of care and service in accordance with all applicable laws, regulations, and Life Care standards. At least three...

  • Regional Director of Clinical Services

    1 month ago

    Aurora, United States Life Care Centers of America Full time

    Salary starts at $115,000. This role requires at least three or more years experience as a Director of Nursing in long-term care. Position Summary The Regional Director of Clinical Services directs the operations, programs and activities of the region to maintain the highest quality of care and service in accordance with all applicable laws, regulations,...

  • Regional Director of Clinical Services

    2 weeks ago

    Aurora, United States Life Care Centers of America Full time

    Salary starts at $115,000. This role requires at least three or more years experience as a Director of Nursing in long-term care. Position Summary The Regional Director of Clinical Services directs the operations, programs and activities of the region to maintain the highest quality of care and service in accordance with all applicable laws, regulations,...

  • Regional Director of Clinical Services

    1 month ago

    Aurora, United States Rocky Mountain Region Full time

    Salary starts at $115,000.This role requires at least three or more years experience as a Director of Nursing in long-term care.Position Summary:The Regional Director of Clinical Services directs the operations, programs and activities of the region to maintain the highest quality of care and service in accordance with all applicable laws, regulations, and...

  • Regional Director of Clinical Services

    2 weeks ago

    Aurora, United States Rocky Mountain Region Full time

    Salary starts at $115,000.This role requires at least three or more years experience as a Director of Nursing in long-term care.Position Summary:The Regional Director of Clinical Services directs the operations, programs and activities of the region to maintain the highest quality of care and service in accordance with all applicable laws, regulations, and...

  • Regional Director of Clinical Services

    5 days ago

    Aurora, United States Rocky Mountain Region Full time

    Salary starts at $115,000. This role requires at least three or more years experience as a Director of Nursing in long-term care. Position Summary: The Regional Director of Clinical Services directs the operations, programs and activities of the region to maintain the highest quality of care and service in accordance with all applicable laws, regulations,...

  • Regional Director of Clinical Services

    1 month ago

    Aurora, CO, United States Rocky Mountain Region Full time

    Salary starts at $115,000. This role requires at least three or more years experience as a Director of Nursing in long-term care. Position Summary: The Regional Director of Clinical Services directs the operations, programs and activities of the region to maintain the highest quality of care and service in accordance with all applicable laws, regulations,...

  • Director of Fulfillment Operations

    3 weeks ago

    Aurora, United States Jobs for Humanity Full time

    Company Description Jobs for Humanity is collaborating with Safelite to build an inclusive and just employment ecosystem. We support individuals coming from all walks of life. Company Name: Safelite Job Description Does this position interest you? You should apply - even if you don't match every single requirement! We're known as an auto glass company....

  • Director of Fulfillment Operations

    2 weeks ago

    Aurora, United States Jobs for Humanity Full time

    Company Description Jobs for Humanity is collaborating with Safelite to build an inclusive and just employment ecosystem. We support individuals coming from all walks of life. Company Name: Safelite Job Description Does this position interest you? You should apply - even if you don't match every single requirement! We're known as an auto glass company....

  • Regional Sales Manager

    3 weeks ago

    Aurora, United States JON-DON LLC Full time

    Description: Our strong reputation for quality customer service has been the foundation of our success. As a Regional Sales Manager, you will be responsible for continuing to impress our customers. This position involves proactively selling solutions to our customers’ problems (whether it's providing product and technical advice). **About Factory Cleaning...

  • Region Sales Manager

    1 week ago

    Aurora, United States Orkin Full time

    Overview: At Orkin, our purpose is to help protect the world where we live, work and play. Our Region Sales Managers are exceptional, experienced sales leaders, devoted to this purpose. As a Region Sales Manager, you will lead and motivate multiple branch sales teams through excellent communication and interpersonal skills. Your focus will be on...

  • Director of Operations

    4 days ago

    Aurora, United States PuroClean Corporate Full time

    Job DescriptionJob DescriptionPuroClean is on the move!! We are growing and HIRING!!!We are looking for a qualified and dedicated industry professional for a Regional Director position.JOB OVERVIEW:Our Regional Directors provide essential support and guidance for our franchisees through all stages of their franchise business. Our Regional Directors are...

  • Regional IT Application Manager

    2 weeks ago

    Aurora, United States Solina USA Full time

    Overview Solina is the leader on the European market of savory ingredients. With 39 production sites and numerous local R&D centers close to its customers, Solina develops tailor-made ingredients for the savory food industry, foodservice and butchery sectors. Solina's expertise combines culinary and technical expertise that enables the company to design...

  • Regional IT Application Manager

    2 weeks ago

    Aurora, United States Solina USA Full time

    Overview Solina is the leader on the European market of savory ingredients. With 39 production sites and numerous local R&D centers close to its customers, Solina develops tailor-made ingredients for the savory food industry, foodservice and butchery sectors. Solina's expertise combines culinary and technical expertise that enables the company to design...

  • Regional Sales Manager

    3 weeks ago

    Aurora, United States Craft-Bilt Mfg. Co. Full time

    Aurora, IL, USA | Base + Commission | Full Time Our mission statement begins with you: Enthusiastic Employees...Flawless Performance...Delighted Customers! Craft-Bilt Manufacturing Co. is a leading American manufacturer of Sunrooms and commercial and residential Awnings and Outdoor Shade Products. We have an immediate opening for a Regional Sales Manager...

  • Regional Sales Manager

    1 week ago

    Aurora, United States Craft-Bilt Mfg. Co. Full time

    Aurora, IL, USA | Base + Commission | Full Time Our mission statement begins with you: Enthusiastic Employees...Flawless Performance...Delighted Customers! Craft-Bilt Manufacturing Co. is a leading American manufacturer of Sunrooms and commercial and residential Awnings and Outdoor Shade Products. We have an immediate opening for a Regional Sales Manager...

  • Management - Director of Operations

    1 month ago

    Aurora, United States Harvestsherwood Full time

    Harvest Sherwood Food Distributors, Aurora, Aurora, Colorado, United States of America Job Description Posted Thursday, March 14, 2024 at 4:00 AM We encourage you to bring your talent and effort to Harvest Sherwood and contribute to our shared success, while having fun, serving our customers, and strengthening the local communities in which we operate. As...