Utilization Management Director Jobs

The Director of Utilization Management (UM) must be a registered nurse well versed in leading teams of clinical personnel in the review and assessment of referrals for specialty care services. This senior leader must be able to contribute to implementing, monitoring, and maximizing systems and processes resulting in timely, appropriate access to and utilization of physician specialty services and improved member health outcomes. The UM Director is also engaged in oversight of utilization management auditing, both internal and external, and development of UM corrective action plans as required for submission to health plans. Provides program outcome metrics to senior leadership and assesses and reports on utilization statistics. Provides engaged, supportive leadership and collaborates cross-functionally with IT, financial analysis, care management, compliance, customer service and claims service departments to identify opportunities for continuous improvement.

Job Responsibilities

• Collaborates with Medical Directors, Chief Medical Officer, and other designated physician leaders regarding clinical decision-making support
• Works closely with internal and external stakeholders to ensure staff and systems have needed data and tools to assess and provide appropriate access to care
• Hire, provide access to training, develop, and build a strong functional team supporting various utilization management activities
• Support various governance and internal committees responsible for utilization management activities
• Assures appropriate resourcing of work required to carry out the clinical review process and support evidence-based decision making related to requests for referral to medical specialty services
• Provide oversight and leadership to the development, implementation, monitoring, and ongoing improvement of the authorization (UM) review process
• Maximizes resource (staff and technology) efficiency by setting clear objectives and establishing accountability for performance with team members
• Ensures that appropriate physician review of referrals requiring clinical review occurs as part of the medical management program
• Prioritizes utilization management activities according to the value, risk, and importance to the organization
• Serve as an interface to health plans; collaborates with the Compliance Department to ensure we provide appropriate access to medically necessary care and meet all applicable regulatory and accreditation standards

Required Experience

• Strong and proven skills in productivity management and process improvement
• 4-7 years of process improvement in a clinical or operations setting within a managed care, medical group, or health plan setting
• Minimum 3 years of demonstrated experience successfully leading and/or turning around teams in a UM setting
• 5-10 years of experience with payor side prior authorization management in California; experience with delegated position groups in California
• Self-motivated with ability to work independently, take charge, and implement change with excellent follow through
• Expertise in NCQA, Knox Keene, and CMS regulatory compliance, plus knowledge of DMHC regulatory requirements

Preferred Experience

• Experience/familiarity with Epic Tapestry authorization systems highly desired

Required Education

• Unrestricted California Registered Nursing license
• Master’s degree in nursing (highly desired)
• Bachelor’s degree in clinical area, hospital or health management or business management

Salary

$180-220K/year

Please note that this position will have bonus earning potential and offers a full suite of benefits including a deferred compensation plan and 401k matching.

At Hill Physicians Medical Group, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.

We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!

Additional Information

We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and one of the “Healthiest Places to Work in the Bay Area.” We have an award-winning Wellness Program, and our average tenure is ~8 years. Every person who joins Hill Physicians is coming in as a leader and has the very real potential to grow with the company as we grow. We’re all in it for the long haul and are bought-in to the success and future of our organization.

We’re proud to have been (and continue to be) a pillar of the Northern Californian healthcare community for more than 30 years. Our more than 5,000 primary care physicians and specialists provide high-quality care across the San Francisco Bay, Sacramento, and Central Valley areas.

By adapting to both the demands of the industry and the needs of consumers, we’ve remained stable and profitable, and our service area now ranges from the Pacific Ocean to the Sierra Nevada’s. We’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.

Our culture is guided by core values​ that promote the health and wellness of our employees and communities (health), commitment (accountability), fiscal responsibility (stewardship), teamwork (collaboration), and our dedication to do the right thing (integrity). 97% of employees feel that supervisors and managers “walk the talk”​ and demonstrate our core values. Join us!

Hill Physicians is an Equal Opportunity Employer

Job Type: Full-time

Pay: $180,000.00 - $220,000.00 per year

Benefits:

• Employee assistance program
• Employee discount
• Life insurance
• Health insurance
• Vision insurance
• Dental insurance
• Flexible spending account
• Paid time off
• 401(k) matching
• Tuition reimbursement
• Referral program
• 401(k)

Physical setting:

• Rehabilitation center
• Office
• Clinic

Schedule:

• 8 hour shift
• Monday to Friday

Supplemental pay types:

• Bonus pay

Ability to commute/relocate:

• San Ramon, CA 94583: Reliably commute or planning to relocate before starting work (Required)

Education:

• Bachelor's (Required)

Experience:

• Utilization management: 4 years (Required)
• Managed care: 4 years (Required)
• Case management: 4 years (Preferred)
• Utilization review: 4 years (Required)
• Project management: 3 years (Preferred)
• Management: 4 years (Required)

Work Location: Hybrid remote in San Ramon, CA 94583