Director, Utilization Management

Summary/Position Objectives:
This position has oversight of the utilization management process for all affiliated health plans, to include prior authorization, concurrent review, case management and disease management. This position identifies, analyzes, plans, develops, organizes, implements and evaluates functions within the health plan utilization management areas. Directs the daily activities of the medical claims review staff.

Responsibilities:
Essential Functions:
Assists health plans in the development and monitoring of the Annual Utilization Management Plan and Annual Evaluation of the Utilization Management activities. Performs annual audits of the health plans Utilization Management Plan.
Keeps abreast of all health plan local medical trends, analyzes patterns that impact the effort to effectively manage utilization and quality of medical services and reports these through the 306090 process.
Develops project budget requirements for affiliated health plans and for medical claims review.
Works with each health plan utilization management to develop innovative approaches to improving cost effectiveness and reduce administrative expenses.
Ensures all health plans have developed and updated utilization management polices, desktops and toolkits based on the SAI standards.
Participates in corporate medical management meetings, programs and projects related to utilization management.
Supervises and mentors medical claims review staff.
Monitors and audits medical claims review staff ‘s evaluation of claims for medically necessary and appropriate level of care, identification and adjustments in billing errors and identification and reporting of fraudulent billing practices.
Mentors Medical Management and related departments in the SAI affiliate health plans, facilitates training and continuing education as needed; serves as a resource to all health plans concerning utilization management issues; encourages and recognizes efforts in quality and economic effectiveness.
Keeps abreast of available utilization management reporting tools and ensure affiliated health plans are educated on the tools and are implementing them in their utilization processes.


ABOUT SCHALLER ANDERSON:

Schaller Anderson administers Medicaid and employer self-funded health plans, and manages behavioral health plans. The company’s suite of services includes member services; provider services; claims processing; information services; financial reporting and analysis; medical management; and grievances and appeals services. Schaller Anderson has also been engaged in several consulting projects for states, health plans and providers. Schaller Anderson and its affiliates have 1,400+ employees nationwide and administer health plans with over 1.6 million members. Recently, the Initiative for a Competitive Inner City and Inc. magazine named Schaller Anderson to the Inner City 100, a list that recognizes the fastest-growing companies in America’s core urban areas. Schaller Anderson placed eighth among 5,000 entries in the Inner City 100 competition and was the only health care management company in the top 10.

The VISION of Schaller Anderson, Inc. is to be recognized as the nation’s foremost managed care resource by providing the highest value management and consulting services throughout the health care continuum.

BENEFITS:

Schaller Anderson team members are provided with countless opportunities to make a real difference and the following compensation/benefits:

* Competitive compensation DOE
* Medical, Dental and Vision insurance
* Employee Assistance Program
* Flexible spending accounts
* On-site fitness center (Phoenix headquarters only)
* Life insurance and accidental death and dismemberment insurance
* Short-term and long-term disability
* Paid holidays, paid time off/paid time off reserve
* 401(k) and profit sharing
* Tuition reimbursement
REQUIREMENTS
Knowledge and Skills:
Incumbent must have skills in management, advanced problem solving and organizational skills. Excellent oral and written communication skills and the ability to prioritize multiple tasks are necessary. Knowledge of Medicaid and Commercial regulatory requirements is helpful. General understanding of URAC and NCQA standards and Medicaid and Federal Health Care regulations. The ability to establish and maintain constructive relationships with diverse members, management, employees, and vendors. The ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution are required. Requires strong problem solving, organizational, and time management skills and ability to work in a fast paced environment. Excellent oral and written communication skills, the ability to manage several tasks/projects simultaneously, and analytical skills are necessary to perform successfully in this role. The ability to successfully utilize Microsoft Office Suite applications and common computer and office hardware is necessary.

Education and Work Experience:
Registered Nurse with a current state license.
Bachelor degree in Nursing or Health Administration and/or health related field (BSN preferred). Master or MBA preferred, but not required.
Five years experience of progressively responsible health care administrative experience, preferably in managed care.
Minimum of three years of management and supervisory experience
Minimum of five years clinical experience.