Director – Utilization Management & Operations

Director – Utilization Management & Operations

Requirements

• Bachelor’s degree in Nursing, Social Work, Healthcare Management or closely related field with 8+ years’ experience in a healthcare payer organization, or equivalent experience required
• 5+ years’ previous utilization review and clinical people leadership experience in a healthcare payer organization required

Responsibilities

• Oversee the Care Management function that assists Medi-Share members in achieving an optimal level of wellness and coordination of their care; helping them identify cost-effective and non-duplicative services while they are in a time of great need and potential crisis
• Develop and ensure the effective delivery of education to members regarding the provisions of their Program Guidelines relative to healthcare, nursing, rehabilitative, and spiritual services
• Provide direction to Care Management staff including, but not limited to hiring, training, and communication regarding policy and procedural changes and monitoring and evaluating the quality of all processes
• Perform and/or administer research in ensuring effective, timely responsiveness to Care and Case Management issues; if required, handoff to Chief Medical Officer, providing required research and recommendation summary
• Act as liaison between member and/or provider to bring about resolution when conflicts arise
• Maintain awareness and be alert to member and provider issue trends and escalating concerns, and recommend resolutions
• Collaborate with other internal teams and stakeholders to ensure timely and accurate determination of sharable services
• Define and manage pre-service eligibility determinations (EDI 278) and associated standard operating procedures
• Define and manage concurrent review processes to effectively manage length of stay and facilitate discharge planning
• Oversee the preparation of various telephone scripts
• Update and maintain the policy and procedure manual
• Maintain the High Priority queue in conjunction with fellow Directors and Chief Medical Officer
• Assist in developing projects, policies, procedures, and other related issues as required
• Support the strategic vision delineated by the Chief Medical Officer and the Ministry
• In coordination with the Chief Medical Officer, organize and staff the Department in a manner that provides optimal service to the members and membership
• Ensure department Managers are successful in workforce, quality, and performance management (as elsewhere delineated)
• Define performance and attendance expectations of department Managers
• Review weekly performance reports submitted by department Managers
• Submit monthly performance reports to the Chief Medical Officer of all staff under Director
• Contribute to the exercise and expression of Christian Care Ministry’s Christian beliefs
• All other duties as assigned

Preferred Qualifications

• Master’s or Doctorate degree in Healthcare Administration (MHA), Healthcare Clinical or Operations Management or similar accredited program preferred
• Experience in a value-based care organization preferred
• Experience in Care Management with understanding of population health and risk stratification principles preferred