Director of Utilization Management

Position Summary:

This position will provide direction and oversight of all Utilization Management (UM) and Case Management (CM) policies, procedures, operations, and compliance. The Director of UM will stay informed on the latest regulatory requirements, contractual obligations, health plan and provider relationships, and the latest medical management technologies to ensure efficient and compliant operations. The Director of UM will have general oversight of department budgetary needs, monitor department efficiency and productivity, and ensure all regulatory requirements are met. The Director of UM will also collaborate with all executive leadership on the needs of the organization and the department.

MUST BE CA BASED.

Essential Duties and Responsibilities:

• Assume responsibility and provide direction on all concurrent review, prior authorization, and case management activities to ensure appropriate, timely, and cost-effective use of health care resources while adhering to all regulatory requirements and ensuring high-quality care for patients.
• Develop and update UM and CM strategies, policies, and protocols in accordance with industry best practices and regulatory requirements.
• Lead and mentor all UM and CM staff and management on daily operations, regulatory compliance requirements, and industry best practices.
• Establish, assess, and enforce key performance indicators for all UM and CM staff including quality of work and productivity standards.
• Stay informed on changing regulations, guidelines, and expectations in the UM and CM fields, and work with company leadership across departments to develop strategies to ensure compliance and enhance operational efficiency.
• Participate in compliance audits for UM and CM including the data analysis, root cause analysis, and strategies to make changes on all issued corrective action plans.
• Participate in all quality improvement activities and collaborate with health care providers, health plans, and regulatory bodies on quality improvement initiatives.
• Participate in and run, as necessary, UM Committee meetings and Interdisciplinary Care Team (ICT) meetings.
• Provides analysis and reports of significant utilization trends, patterns, and resource allocation. Collaborates with medical directors, executive leadership, and other directors to develop improved utilization of effective and appropriate services.
• Ensuring alignment of UM and CM strategies with policy, payment integrity, and network development strategies to optimize quality and cost of care.
• Responsible for oversight and direction of all strategic projects and supporting operational initiatives.
• Responsible for ensuring consistent and timely interrater reliability studies are conducted on all UM staff at a minimum of an annual basis.

Essential Skills, Knowledge, and Abilities:

• Understanding of industry regulations and best practices to optimize operations to meet compliance.
• Excellent written and verbal communication skills.
• Proficiency in data analytics and reporting logic and development.
• Knowledge of CMS, DMHC, health plan, and health care guideline policies and procedures.
• Strong knowledge of medical terminology, ICD-10 and CPT coding, contract and DOFR interpretation, and reimbursement methodologies.
• Skilled in Microsoft Office including Outlook, Word, Excel, PowerPoint, and Visio.
• Ability to prioritize, organize, and multi-task in a fast paced, frequently changing, and demanding environment while meeting deadlines and turnaround time requirements.
• Strong critical thinking and problem-solving skills.
• General understanding of project management concepts and techniques.
• Ability to represent the organization to current and potential customers, health care providers, health plan representatives, executive leadership, and at industry events and conferences.
• Strong judgement and ability to make critical business decisions in the best interest of the organization.
• Experience in budget planning and effective and efficient resource allocation.
• Sound time management and attention to details.

Education Requirements:

Required:

• Bachelor's degree in nursing or Master's degree in health care administration or business administration

Preferred:

• Master's degree in nursing
• Case management or Utilization Management certification

Work Experience Requirements:

Required:

• 10 or more years' experience in a health plan, IPA/medical group, MSO, or hospital in a utilization or case management capacity.
• 6 or more years of management experience in a health plan, IPA/medical group, MSO, or hospital setting.
• Health plan or similar health care organization structure experience
• 5 or more years' experience in a health care compliance capacity

Preferred:

• Contracting and/or Claims experience

Job Type:

Full-time Pay:

$140,000.00 - $170,000.00 per year

Benefits:

401(k) Dental insurance Health insurance Paid time off Vision insurance

Work Location:

Hybrid remote in Murrieta, CA 92563