Commonwealth Care Alliance - Director, Utilization Management
Location: Boston, Massachusetts
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. 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.
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.
- Ensures that utilization management processes are integrated with care management and care delivery processes.
- Leads and organizes the ongoing evaluation of the utilization management program against quality and utilization benchmarks and targets.
- Identifies opportunities for improvement and manages outcome improvement initiatives.
- 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.
- Directs the work of the utilization management team to ensure quality, interrater reliability, and standards are met in daily operations.
- Provides expert input to Finance regarding patterns of utilization and cost, and high-cost cases.
- Member of health plan QI Committee and 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 of managed care operations experience, including a minimum of five (5) years of leadership experience in Utilization Management (UM) or nursing leadership.
- Minimum three (3) years of management experience in a health plan environment.
- Minimum 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.
- Strong communication skills, both verbal and written.
- Ability to manage multiple tasks and priorities in a matrix environment.
- Proven ability to influence and lead; well-developed team-building skills.
Required Language(s):
Desired Language(s):
EEO is The Law
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled
Please note employment with CCA is contingent upon acceptable professional references, a background check, and verification of a valid MA/RN license (if applicable).
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