Director Utilization Management

Dignity Health one of the nation’s largest health care systems is a 22-state network of more than 9000 physicians 63000 employees and 400 care centers including hospitals urgent and occupational care imaging and surgery centers home health and primary care clinics. Headquartered in San Francisco Dignity Health is dedicated to providing compassionate high-quality and affordable patient-centered care with special attention to the poor and underserved. For more information please visit our website at www.dignityhealth.org. You can also follow us on Twitter and Facebook.

Position Overview:

The Utilization Management (UM) Director is responsible for the market(s) development, implementation, evaluation and direction of the Utilization Management Program and staff in support of the CommonSpirit Health Care Coordination model. The Utilization Management department processes authorizations, inpatient admission and continued stay reviews, retrospective authorizations utilizing standardized criteria to determine medical necessity; reviews and processes concurrent denials that require medical necessity determinations; processes appeals and reconsiderations. In collaboration with the Division Director Care Coordination, the UM Director develops strategies to achieve departmental and CommonSpirit Health goals and objectives. This position directs the UM staff to meet or exceed operational performance standards. The Director oversees development and implementation of UM policies, procedures and processes; directs and assists with accreditation activities; efficient management of payer requirements, addressing denials effectively, and compliance with payer and regulatory requirements, and reviews and analyzes UM program outcomes and quality metrics.

#LI-DH

Required Qualifications:

• Current California RN license
• Bachelor's degree in Nursing, Health Care Administration or advanced clinical degree.
• Minimum of three (3) years clinical case management (Utilization Management, denial management, care coordination)
• Five (5) years of progressive responsible management experience
• Extensive operational experience in managed care; extensive experience in program planning, implementation, staff development, and needs assessment
• Comprehensive knowledge of Utilization Management, financial management including revenue cycle, Medicare, Medicaid, and commercial admission and review requirements
• National Certification of any one of the following:  CCM (Certified Case Manager), ACM (Accredited Case Manager) required OR obtain within two (2) years of hire

Preferred Qualifications:

Master's degree in Nursing, Health Care Administration or related clinical field

Experience with data analytics to include cost containment, over/under utilization assessment and clinical outcomes

Experience with DRG, reimbursement, pricing and coding processes for inpatient and outpatient services