Utilization Management Director

Overview

Chinese Hospital, a community-owned, not-for-profit organization, exists primarily to deliver quality health care in a cost-effective way, responsive to the community’s ethnic and cultural uniqueness, providing access to health care and acceptability to all socioeconomic levels, partnering with CCHP.

CCHP’s mission is to improve the health of our community by delivering high-quality, affordable healthcare through culturally competent and linguistically appropriate services. We welcome all cultures and in any language.

CCHP is looking for a Utilization Management Director.

The Utilization Management Director position is a vital leadership role that provides oversight of all aspects of the Utilization Management Program, day-to-day operations and staff to ensure service levels, business functions and all regulatory requirement goals are met. Working closely with CCHP leaders, the UM Director plans, executes and reports on administrative, operational and strategic objectives. Together with the UM Medical Director and UM Behavioral Health practitioner, collaborates in setting annual department goals and interventions and provides routine progress reports to stakeholders.

The UM Director is involved in reviewing and making determinations on authorization requests and providing training and subject matter expertise to other departments as needed to ensure efficient utilization management.

The UM Director represents CCHP in the healthcare community both in the Bay Area and with out-of-area hospitals. In this role the UM Director actively and consistently fosters a positive and collaborative working relationship with CCHP’s community partners, contracted hospital transfer centers, nursing supervisors, and medical group Utilization Management (UM) nurses.

Essential Duties and Responsibilities

• Provides clinical leadership and management to the UM department by managing the day-to-day operational functions.

• Routinely analyzes and reports UM metrics to identify trends and recommend interventions to the Medical Director and the UM QI Committee.

• At least annually, reviews all desktop procedures, and operational policies and procedures annually; revises and implements under the direction of the UM Medical Director.

• Conducts an annual assessment of operational processes to enhance departmental and interdepartmental accuracy and efficiency.

• Provides clinical review including high risk member reporting for the finance and claims department.

• Routinely monitors turnaround times for authorizations, denial letters and member notification of services, and productivity.

• Is a subject matter expert who can develop resource tools and education for the clinical and administrative staff.

• As a business leader supports the compliance department in maintaining compliance with state and federal requirements for the UM department and implements corrective action plans that address findings to maintain compliance.

• Serves as primary liaison with all delegated medical group UM departments, Chinese Hospital nurse leaders, community hospitals and transfer centers.

• Provides leadership in the design and implementation of UM policies, processes, and procedures needed to meet National Commission on Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC) accreditation requirements for all lines of business.

• Maintains knowledge of the UM software program functionality and collaborating with the IT team responsible for advising on replacement, upgrades, and user testing

• Conducts annual employee evaluations for licensed and non-licensed UM staff.

• Performs other duties as assigned by the Medical Director.

Core Competencies

Must possess and consistently demonstrate the following competencies:

Decision Making and Judgment

• Coordinates cross-functional resources and ideas to align with organizational goals.

• Conducts root-cause analysis to uncover underlying issues and recommend effective solutions.

• Develops and evaluates a range of solutions, assessing benefits, costs, and risks associated with each.

• Interprets data to identify trends, draw conclusions, and present findings.

Teamwork

• Promotes a…