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Job Details: Director, Utilization Management

Job Details: Director, Utilization Management
On-Line Application
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+ Vacancy NoVN2072
Posting TitleDirector, Utilization Management
Location CityCharlestown
Language Requirement
Job Description
Position Summary:
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 of Utilization Management reports to the Senior VP of Clinical Operations and 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 Chief Medical Officer and VP of Medical Affairs to develop and advance the UM program. Furthermore, this role collaborates with the Behavioral Health UM team as well as CCA's clinical groups and provider partners in care management and care delivery. Additionally, the director oversees the delegated entity UM functions and supports initiatives with providers and members to ensure the appropriate utilization of services.
Responsibilities:
+ 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.
+ Ensures staff selection, training, and performance monitoring and
+ 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
Minimum Qualifications:
+ Bachelor's Degree or equivalent experience, required.
+ Master's degree in Business or Health related field preferred.
+ 8 or more years of managed care operations experience including a minimum of three years of management experience in health plan environment with responsibility for managing utilization management, case/disease management, program development/management/evaluation and/or quality improvement.
+ Active RN license required.
+ Medicare and Medicaid managed care experience.
+ Demonstrated knowledge of federal and state regulations relevant to utilization management.
+ Demonstrated knowledge of healthcare 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.
Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable).
Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.
CCA is committed to protecting the health of our workforce and our members, and we encourage flu vaccination in accordance with CDC recommendations. Individuals working in clinical care areas or in direct contact with members must provide documentation of flu vaccination, or wear a mask during flu season whenever engaged in member-facing activities.
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