Why This Role is Important to Us:
The Director of Utilization Management leads and manages all utilization management (UM) functions for physical health services and long-term services and supports to ensure achievement of business results while maintaining compliance with all contract requirements, state and federal regulatory requirements, and all applicable accreditation standards. The Director is responsible for setting strategic direction, planning, budgeting, policy development, and business process management and improvement for all UM functions. This role works closely with the CMO and VPMA to develop and advance the UM program, collaborates with the Behavioral Health UM team, multiple clinical groups, and provider partners in care management and care delivery, oversees the delegated entity UM functions, and supports initiatives with providers and members to ensure the appropriate utilization of services.
Supervision Exercised: Yes
What You'll Be Doing:
- Directs, coordinates, and evaluates efficiency and productivity of utilization management functions for physical health services and long-term services and supports. Works closely with delegated entities, pharmacy, dental, and other vendors to assure integration, oversight, and efficiency of UM processes and functions.
- Ensures compliance with all contract requirements, state and federal regulatory requirements, and all applicable accreditation standards in improvement to promote the development of a high-quality team collaboration with the broader clinical organization.
- Ensures that utilization management processes are integrated with care management and care delivery processes.
- Works closely with the CMO and VPMA to develop and advance the UM program and leads and organizes the ongoing evaluation of the utilization management program against quality and utilization benchmarks and targets. Identifies opportunities for improvement; organizes and manages outcome improvement initiatives.
- Ensures staff selection, training, and performance monitoring.
- Leads the Utilization Management team in managing and continuously improving UM program design, policies, procedures, workflows, and correspondence.
- Supports provider relations and provider contracting leaders in the design and implementation of successful methods for working with providers. Ensures integration of utilization management functions with network strategy, vendor relationship management, and claims processing. Works closely with provider relations on resolving provider-related issues.
- Directs the work of the utilization management team to ensure quality, interrater reliability, and standards are met in daily operations. Responsible for resolution and communication of utilization management issues and concerns and corrective action plan activities and reporting.
- Provides expert input to Finance regarding patterns of utilization and cost and high-cost cases.
- Member of health plan QI Committee. Co-chair of health plan Utilization Management Committee.
Working Conditions:
- Standard office conditions.
What We're Looking For:
Required Education:
- Bachelor's Degree or equivalent experience.
Desired Education:
- Master's degree in Business or Health related field preferred.
Required Licensing:
- Active RN license required.
Required Experience:
- 7-10 years.
- 8-10 years of managed care operations experience, including a minimum of five (5) years of leadership experience in Utilization Management (UM) or nursing leadership to include a minimum of two (2) years of leadership experience in UM.
- Minimum of three (3) years of management experience in health plan environment with responsibility for managing the effective utilization of healthcare services, case/disease management, program development/management/evaluation, and quality improvement.
- Minimum of five (5) years of clinical experience in medical or behavioral health care delivery.
Required Knowledge, Skills & Abilities:
- Medicare and Medicaid managed care experience.
- Demonstrated knowledge of federal and state regulations relevant to utilization management.
- Demonstrated knowledge of health care industry trends, developments, and issues.
- Must have experience overseeing contractual performance standards.
- Demonstrated ability to utilize oral and written communication skills and interpersonal skills such as influence, negotiation, persuasion, and conflict resolution.
- Proven ability to influence and lead; well-developed teambuilding skills, unquestioned integrity, and the experience, confidence, and stature to effectively address sensitive member issues.
- The ability and desire to embrace and manage change; demonstrated ability to maintain a high level of productivity and drive effectiveness in the midst of ambiguity or stress.
- A commitment to excellence and to making a difference; results-driven, improvement-focused, and action-oriented leader who proactively and continually looks for better ways of doing things.
- Demonstrated passion and commitment to positive and effective customer service focusing on needs of members and internal customers delivering extraordinary results; must be able to operate in a positive, helpful, and productive manner; a record of success in managing customer-focused teams.
- Business acumen/organizational awareness; business insight and the ability to make a contribution to the organization as a whole; strong strategic thinking and analytical skills; excellent organizational skills and demonstrated attention to detail.
- Proven ability to influence course of action when others are directly accountable for outcomes.
- Strong and effective communication skills, both verbal and written; the presence, confidence, influencing, and communication skills to effectively represent the company to a variety of audiences.
- Experience with managing clinical services for Medicaid/Medicare patients.
- Demonstrated ability to lead and navigate large scale organizational projects and evolution.
- Ability to manage multiple tasks and priorities in a matrix environment, strong problem-solving skills, and attention to detail.
- Demonstrated ability to interface and present to senior management effectively.
- Competent in working with vulnerable and diverse populations.
- Ability to work under pressure and meet deadlines.
Required Language(s):
Desired Language(s):
Actual Work Location: Boston, Massachusetts 02108
All Locations: Boston, MA
Exempt / Not Exempt: Exempt
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