Director Of Utilization Management

Wage Range: $120,000/year to $144,000/year

Job Summary

The Director of UM position provides oversight and leadership of all aspects of the Utilization Management operations and staff to ensure service levels, business functions and goals are met. Develop and foster a professional working relationship with Clever Care Health Plan Network providers to ensure opencommunication. Development of policies, procedures, and front line staff practices to ensure contract compliance

Responsible for day to day operations of the Utilization Management functions including prior authorization, concurrent review and direct supervision of the clinical and non-clinical prior authorization, transitions of care, implementation of supplemental benefits and concurrent review teams. Ensure department meets turnaround times and all other quality measures. Coordination and achievement of the Utilization Management business function goals and objectives; set team goals and fulfill the goals each year.   Lead discussions with Clever Care providers and IPA partners to refine procedures for PA submissions, concurrent review of inpatient.  Ensure compliance with State and CMS regulations by timely submission of reports.  Engage contracted IPA’s and MSO’s to ensure timely submission of prior authorizations, monitor turn around times, c attendance and submitting reports on time are additional responsibilities of the UM Manager position.  Develop and maintain job descriptions and hiring and training UM staff. Will act as back up to prior authorization/Concurrent Review staff as needed.  Collaborate with internal  teams to optimize workflows to achieve organizational goals. 

Functions & Job Responsibilities

• Responsible for oversight and leadership of the UM program to meet all CMS and other regulatory agency requirements
• Meet and exceed department service, operational and financial goals, provide analysis, identification of variances and develop action plans to achieve established goals. Report unit performance to internal and stakeholders as required.
• Participate in the development and implementation of departmental policies and procedures, and monitor/ensure compliance and consistency, Review and revise workflows and procedures to ensure maximization of resources and excellence in customer service.
• Responsible for departmental and individual performance monitoring and providing staff timely and honest feedback on their performance. Identify areas where improvement is needed and obtain timely training and development of staff, and corrective action plans when needed.
• Development of departmental budget, goals, and objectives.
• Lead joint operations committee meetings with IPA’s & MSO’s for all UM related functions including reporting of relevant metrics and goals
• Prepare monthly utilization reports for Clever Care leadership:  bed day performance, key turnaround time measurements, outlier bed day analysis.
• Develop policies for implementation of supplemental benefits (SSBCI) and provide monthly reports on utilization of these benefits
• Lead development of transitions of care (TOC) program to improve readmission rates
• Other duties as assigned.

Leadership Expectations

By way of leadership approach, mobilize others to create extraordinary results, and unite people to turn challenges into successes by championing the following:

1. Model the Way:

• Clarify values by finding your voice and affirming shared values
• Set the example by aligning actions with shared values

2. Inspire a Shared Vision

• Envision the future by imagining and sharing exciting possibilities
• Enlist others in a common vision by appealing to shared ambitions

3. Challenge the Process

• Search for opportunities by seizing the initiative and looking outward for innovative ways to improve
• Experiment and take risks by consistently generating small wins and learning from experience

4. Enable Others to Act

• Foster collaboration by building trust and facilitating relationships
• Strengthen others by increasing self-determination and developing competence

5. Encourage the Heart

• Recognize contributions by showing appreciation for individual excellence
• Celebrate the values and victories by creating a spirit of community
   

Qualifications

Education and Experience

• Bachelor’s degree in Business or Administration
• Three (3) to five (5) years of health plan/healthcare management/leadership experience in related field
• Active RN License in state of California

Skills

• Excellent oral and written communication and interpersonal skills
• Rapid problem resolution.
• Exceptional attention to detail while multi-tasking.
• Ability to work independently and collaboratively within a team.
• Strong organizational skills
• Ability to communicate, facilitate and problem- solve with people of all levels of the organization, as well as provider networks, vendors and constituents
• Ability to perform analysis and apply sound reasoning in problem solving
• Ability to manage time and prioritize tasks
• Ability to solve practical problems and deal with a variety of concrete variables in situations where some standardization exists; ability to collect and analyze data, draw valid conclusions and actively contribute to the strategic interventions that support the departmental goals.
• Strong planning and analytical skills
• Effective management and leadership abilities

Physical & Working Environment.

Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

• Must be able to travel when needed or required  
• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
• Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.

Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.

Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.

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