Director, Utilization Management

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Come join Peak Health – a fast-growing provider led health plan. This role will be responsible for the people, process and business requirements necessary to appropriately manage care and deliver exceptional customer service. Reporting to the Health Plan Senior Leadership, The Director, Utilization Management will be an integral member of the health plan’s senior leadership team.

This role will be responsible for directing the utilization management team to ensure the appropriate application of policy procedures and processes to help support member outcomes. The Director, Utilization Management will oversee and manage the team specific to the daily operations of Utilization Management including timeliness, quality and performance outcomes, provider interactions and experience and associated regulatory and/or compliance measures.

In addition to the daily responsibilities the Director will lead utilization management team on performance, improvement, and career growth path considerations. The Director will also oversee utilization management team policies and procedures to ensure compliance with corporate, state, and National Committee for Quality Assurance (NCQA) standards including pursuit of accreditation as needed to support Peak product objectives. The Director will also be expected to review, analyze, and report on utilization trends, patterns, and impacts to deliver an effective utilization program.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

• Bachelor of Science in Nursing (BSN) from accredited nursing program.

EXPERIENCE:

• Five (5) years of prior management experience in Utilization Management in a managed care setting.
• Eight (8) years of experience working in Utilization Management.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

• Master of Science in Nursing (MSN).

EXPERIENCE:

• Utilization Management for Medicare and/or Medicaid populations.

CORE

DUTIES AND RESPONSIBILITIES:

The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

• Leads utilization management team policies and procedures to ensure compliance with corporate, state, and National Committee for Quality Assurance (NCQA) standards.
• Leads utilization management team on performance, improvement, and career growth path considerations.
• Leads process improvements for the utilization management team to achieve cost-effective healthcare results and presents to senior leadership team.
• Hires and manages an engaged workforce to deliver exceptional customer service and quality.
• Sets team direction, resolves issues and provides mentoring and guidance to team.
• Executes the overall strategy for onboarding, hiring, and training new utilization management team members to ensure adequate training and high quality-care to improve member and provider experience and ensure compliance.
• Responsible for components of the department's budget while collaborating inter-departmentally with senior leadership.
• Reviews, analyzes, and reports on utilization trends, patterns, and impacts to deliver an effective utilization program.
• Leads and manages others in a matrixed/cross functional environment with tight time frames and strict deadlines.
• Ensures operational and regulatory compliance with all documentation and turnaround times for utilization management work queues across all product lines.
• Optimizes utilization management workflows and prior authorization protocols across global capitation and traditional FFS reimbursement strategies.
• Complies with all policies and standards.
• Performs other duties as assigned.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential…