Director, Utilization Management

Summary

• 100% employer health plan for employees and their eligible dependents
• Unique benefit offerings that are partially or 100% employer-paid
• Rich and varied retirement plans with the opportunity to participate in multiple plans
• Generous paid time off plans

Role Overview:

Alameda Health System is hiring! The Director of Utilization Management plays a critical role in overseeing operations, strategic planning, compliance, and collaboration. Responsibilities include managing admissions, ensuring clean claims, identifying trends, and optimizing resource utilization. This role supports patient care coordination, fosters physician collaboration, and aligns with organizational objectives while handling ad hoc duties as needed. Essentially, they orchestrate efficient utilization management to deliver high-quality patient care.

DUTIES & ESSENTIAL JOB FUNCTIONS
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NOTE:

These are the duties performed by employees in this classification. Employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in this classification.

• Lead and manage a team of utilization review professionals, providing guidance, training, and performance evaluations.
• Monitor and evaluate healthcare service utilization, including appropriateness, efficiency, and medical necessity of treatments and procedures.
• Analyze data and generate reports on utilization trends, outcomes, and quality indicators to support decision-making and process improvements. Reports are submitted to appropriate committees.
• Manage quality performance criteria, policies, procedures, and service standards for utilization management operations. Evaluate reviews and determine program improvements.
• Develop and implement utilization review policies and procedures in accordance with industry standards and regulatory requirements.
• Coordinate data gathering and record keeping required by federal and state agencies, the Joint Commission, and hospital policies; participate in risk mitigation and process improvement projects.
• Foster effective communication and collaboration with internal departments, external agencies, and insurance providers to facilitate utilization review.
• Participate in interdisciplinary committees and meetings to contribute to quality improvement initiatives.
• Oversee secondary review processes; actively appeal denied cases when necessary and assist physicians with appeals. Maintain minimal denial rates from Medicare, Medi Cal, private, and contracted payers through proper utilization practices; support physicians and hospital staff in understanding utilization management matters.
• Perform other duties as assigned.
• Prepare cost analysis reports and other data for departmental budget planning.
• Provide in-house educational programs for staff and physicians as needed.
• Handle recruitment, orientation, evaluation, counseling, and disciplinary actions for utilization management and administrative staff.
• Serve as a content expert to staff, internal departments, and external partners; network with hospitals, nursing organizations, and professional bodies to stay updated on industry changes.

MINIMUM QUALIFICATIONS

Required Education: Bachelor’s degree in Nursing

Preferred Education: Master’s degree in Nursing

Required Experience: Three years of utilization review experience, including work in health insurance companies and/or acute care hospitals, post-acute, and psychiatric settings; experience with Inter Qual and/or MCG; strong clinical nursing background.

Required Licenses/Certifications: Valid license to practice as a Registered Nurse in California.

Preferred Licenses/Certifications: UM / CM certifications