Director of 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.

Secondary Functions:
- Develops responses to Requests For Proposal (RFP).
- Assists with implementation of new health plans.
- Completes special projects as assigned.
- Attends and participates in committee meetings as delegated.
- Assures timely performance evaluation of medical claims review staff.
- Works in a manner that is not disruptive to peers, supervisors and/or subordinates.
- Must maintain regular and acceptable attendance at such level as is determined in the employer’s sole discretion.
- Must be available and willing to work such days and hours as the employer determines are necessary or desirable to meet its business needs.
- Must be available and willing to travel to such locations and with such frequency as the employer determines is necessary or desirable to meet its business needs. (If travel required.)

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.

Work Environment Qualifications:
Position is a computer station, office environment. Incumbent is expected to sit for extended periods. Incumbent will have one-on-one contact with other employees in a quiet environment where hearing and listening is paramount. Incumbent must generate written work using a computer/keyboard. This position is required to work to project timelines, and at time may deal with significant time pressures. Incumbent is expected to use diplomacy and problem-solving skills to procure data and information from other sources, as well as handle incoming public inquiries.

Positions Reporting:
Medical Claims Review Staff