Director, Regional Utilization Management
DescriptionJob
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 Washington 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.
QualificationsBasic
Qualifications:
ExperienceMinimum eight (8) years clinical and medical utilization/review experience.
Minimum five (5) years supervisory/management experience.
EducationBachelors degree in related field OR four (4) years of experience in a directly related field.
High School Diploma or General Education Development (GED) requiredLicense, Certification, RegistrationLicensed Independent Clinical Social Worker (Washington) OR Registered Nurse License (Washington)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.
Job Field:
QA / UR / Case ManagementJob Type:
StandardSchedule:
Full-timeJob Level:
Director/Senior DirectorTravel:
Yes, 10 % of the TimeEmployee Status:
Regular.
Estimated Salary: $20 to $28 per hour based on qualifications.
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 Washington 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.
QualificationsBasic
Qualifications:
ExperienceMinimum eight (8) years clinical and medical utilization/review experience.
Minimum five (5) years supervisory/management experience.
EducationBachelors degree in related field OR four (4) years of experience in a directly related field.
High School Diploma or General Education Development (GED) requiredLicense, Certification, RegistrationLicensed Independent Clinical Social Worker (Washington) OR Registered Nurse License (Washington)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.
Job Field:
QA / UR / Case ManagementJob Type:
StandardSchedule:
Full-timeJob Level:
Director/Senior DirectorTravel:
Yes, 10 % of the TimeEmployee Status:
Regular.
Estimated Salary: $20 to $28 per hour based on qualifications.
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