Director Of Utilization Management Clinical Programs

The Clinical Program Director of Utilization Management (UM) is accountable for developing and maintaining the framework to achieve efficient and effective clinical programs across in-patient, prior authorization, and post- acute including DME and homecare. The Director is responsible for the development of, and ongoing improvement in, standardized clinical decision making in accordance with the appropriate state and federal coverage determinations, product benefits, internal medical policies and InterQual criteria . This includes responsibility for robust performance management for the clinical team in collaboration with the medical review team and Medical director of Utilization Management. The director also works in collaboration with the Operations Director of UM, the Medical Director, the Vice President of UM and the Chief Clinical Officer to determine the most effective measures to improve quality of care and reduce TCOC through analysis of over and under- utilization. The Director is accountable for the continuous assessment of the clinical program effectiveness and is responsible for identifying opportunities for improvement, assessing risk and communicating observations, recommendations and results to the VP of UM. The Director is also responsible for identifying ways to integrate clinical UM functions with case management, pharmacy and behavioral case management.

Key Functions/Responsibilities:

Process

• Develops, implements and evaluates departmental policies, processes and procedures that ensure efficiency, effectiveness, quality and consistency and meet regulatory requirements.
• Develops and monitors performance and quality metrics, including audits and call monitoring. Notifies the VP of UM if performance falls below expectations, and works with leadership to develop a plan to improve performance.
• Leads and oversees the UM component of highly visible and complex initiatives (new clinical programs, prior authorization changes, home care and DME advances. Leads team to ensure that regulatory and accreditation standards for turnaround and documentation are met.
• Analyzes metrics and other information to substantiate results.
• Proactively identifies opportunities to improve existing processes or add new processes and recommends/proposes solutions to improve outcomes across the department. Anticipates downstream impacts of workflow/ process changes to UM department and other departments in the end to end process.
• Works with the Operations Director to ensure the timely and accurate production of regulatory and contractual reporting.
• Acts as a liaison to Legal, Compliance and Quality Department on issues that have both legal risk and compliance aspects and coordinates with the Accreditation Manager on NCQA audits as well as being responsible for all corrective actions in assigned area.
• Assists the VP of UM in development and management of the department budget
• Represent BMCHP/Well Sense UM operations externally as appropriate such as meetings with provider groups and state agencies.
• Attends and participates in UM governance and Quality committees as assigned.
• Develops a high performance team as evidenced by
• Meeting all process requirements
• Eliciting the team’s participation in identifying opportunities for improvement
• Meeting defined team goals such as targeted results of an annual team survey
• Developing performance management skills in supervisory staff by modeling, managing, and setting clear expectations
• Oversees the development and execution of individual professional development plans for all direct reports consistent with the corporate performance management program.

Data/Technology

• Oversees the consistent use of support technologies
• Develops reporting with Analyst by thoroughly understanding needs, purpose and requirements
• Develops departmental targets, measures and metrics and integrates their meaningful use across all department functions and team members
• Continuously evaluates tools and technologies to identify new opportunities for efficiency or effectiveness across all staff in the department
• Works with other business areas including IT, Clinical Informatics, and Quality as related to business requirement development , clinical management software configuration, and UA

• Bachelor’s Degree required
• Registered Nurse
• Master’s Degree in Healthcare or related field preferred
• Lean or Six Sigma certification preferred

• 7 or more years of progressively responsible management experience required
• 5 or more years of experience with Medicaid/Medicare Managed Care or other health plan experience required
• Acute In-Patient and Ambulatory preferred

• Experience with Medicaid/Medicare recipients and community services
• Jiva, InterQual® or other healthcare systems experience
• Health plan or insurance environment experience
• Experience in an operations environment with regulatory turnaround times
• Utilization Management experience
• Experience managing cross functional projects

• Active licensure as a Registered Nurse

• Experience managing complex processes
• Attention to detail
• Ability to meet aggressive time lines when required
• Ability to develop a high functioning team
• Experience with data driven decision making
• Knowledge of metrics, and an ability to compile, format, interpret, and present data
• Mastery of verbal and written communication skills, including but not limited to the ability to translate complex subject matter into understandable information tailored to specific audiences
• Ability to successfully plan, organize, implement and manage projects within a health care setting
• Strong working knowledge of Microsoft Office applications
• Aptitude for matching business requirements to potential software solutions
• Strong analytical and problem solving skills
• Knowledge of process improvement techniques

• Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.