Director, Utilization Management
Bcidaho

Job Info

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We are looking for a Clinical Director to lead all aspects of utilization management (UM) within our Healthcare Operations team!

This role is responsible for directing the overall strategy, operational performance and outcomes of the department's activities. You will develop, direct, and monitor all work related to utilization management (UM) authorizations for pre-service, concurrent, and post-service medical necessity reviews. You will also provide leadership and oversight of the department and for meeting organizational performance goals and objectives.

This role is located in Meridian, Idaho, reporting to the VP, Medical Management. #LI-Onsite

We're seeking a leader with:

• Experience: 10 years clinical experience to include utilization management and leadership
  
• Education: Bachelor's Degree in Nursing or equivalent work experience (Two years' relevant work experience is equivalent to one-year college)
  
• Certifications/Licenses: Current unrestricted Registered Nurse (RN) Licensure in the State of Idaho or able to obtain licensure in Idaho
  

Knowledge of:

• In depth understanding of UM/UR processes
  
• In depth understanding of prior authorization compliance rules, regulations, protocols, and standards
  
• In depth understanding of system operations related to UM, authorizations, and timelines
  
• Familiar with CMS regulations and NCQA compliance standards related to UM
  
• Able to understand data and reports, and reporting applications
  
• Understanding of health plan operational processes.
  

Skills:

• Microsoft Office (Word, Excel, Access, PowerPoint)
  
• Excellent written and verbal communication skills
  
• Ability to construct and implement sophisticated operational workflows processes and procedures
  
• Highly proficient in successful completion of complex system related projects
  
• Comfortable in span of control and influencing colleagues and leaders toward project goals
  
• Ability to establish strategic direction through securing information and identifying key issues and relationships relevant to achieving a long-range goal or vision.
  
• Leadership skills to advise others and maintain a common vision for project objectives.
  

Ability to:

• Influence
  
• Travel occasionally
  
• Collaborate in a matrix reporting structure
  

We would love it if you also had:

• Health Plan experience
  
• Management/Leadership Experience at a Director Level
  
• Graduate of an accredited school of nursing with a master's degree
  
• UM/CM Certification and or training
  
• Expertise in the use and application of medical review criteria tools- InterQual and or MCG
  
• Demonstrated experience with Center for Medicare and Medicaid Services (CMS) regulations and the National Committee for Quality Assurance (NCQA accreditation.
  

In this role, we will ask you to:

• Design and ensure appropriate processes are in place to comply with appropriate accrediting agencies for goals achievement.
  
• Monitor and evaluate staff UM decisions analyzing quarterly reviews, appeals, physician decision trends and provides reports on performance.
  
• Act as the lead representative for UM authorizations to CMS and other regulatory entity requests as it related to medical review.
  
• Develop and deploy utilization review processes for new lines of business, as needed.
  
• Serve as organizational consultant regarding UM
  
• Chair and/or Co-chair monthly utilization review committee. Prepare reports for committee and leadership analyzes trends, recommends develops and deploys solutions.
  
• Engage with local hospitals in Joint Operating Committees.
  
• Engage with ongoing performance management with staff including coaching, mentoring and development of succession planning.
  
• Collaborate with Medical Director and/or Associate Medical Directors to improve workflows and resolve complex medical review issues.
  
• Develop, implement and continually monitor all utilization management policies and procedures and ensures annual review and revision.
  
• Work with analytics to modify reporting as needed. Monitor monthly utilization patterns, identified outliers and lead efforts to address inappropriate overutilization and/or trends.
  
• Provide support to team and provide periodic updates of UM and PA objectives, projects and initiatives in numerous forums to various committees, and workgroups.
  
• Work collaboratively with Information Technology to craft, select, update and maintain UM and Authorization platforms.
  
• Act as a subject matter authority and resource to internal and external departments for UM, PA, Concurrent and Post-service reviews.
  
• Participate in communication with employers, providers, regulatory agencies, members and families as applicable to scope of work.
  

Reasonable accommodations

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

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