Utilization Management Director Jobs

Organizational Description

The Community Health Center Network (CHCN) is a partnership between eight health service organizations in Alameda County, whose mission is to provide a comprehensive range of professional health care in a manner respectful of the community values and traditions. CHCN is a nonprofit corporation, serving as an agent for its member health service organizations. CHCN provides administrative support to the Alameda Health Consortium (AHC).

Position Title:Utilization Management Director

Department:Healthcare Services

Reports To:Chief Medical Officer

Classification: Exempt

Status:Full Time Regular

Salary Range: $133,400 to $176,800 yearly

Candidate must be willing to have primary residence in California. For licensing and tax purposes, we are unable to hire candidates residing outside of the state of California starting on the date of hire.

POSITION SUMMARY

The UM Director oversees the staff and activities of the Utilization Management (outpatient and inpatient) and Basic Case Management programs. They develop, update, review and provide oversight of Utilization Management and Care Management processes, policies and procedures, ensuring compliance with applicable federal, state and delegated health plan requirements. Responsible for all Management Services Organization (MSO) delegated requirements.

ESSENTIAL POSITION RESULTS

The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks and responsibilities. Employees may perform other duties as assigned.

• Provide oversight for utilization management including: representation at health plan meetings and audits; development and maintenance of utilization management and case management plans, policies, procedures, and reports.

• Serve as a leader and role model for the UM department and the MSO, working in close partnership with staff, medical officers, business operations, finance, quality and other departments/divisions of the organization.

• Conduct training for staff and the organization on UM related matters.

• Responsible for effectively managing the Care Management program including program development, staff training and support, and work with external partners.

• Supervise Utilization Management Supervisors (outpatient and inpatient), Basic Case Management team, and other teams as the organization requires, such as UM Quality Improvement.

• Responsible for the oversight of processing of prior authorizations, concurrent and out-of-plan reviews, and denials according to regulatory and internal standards.

• Work with the team to support quality improvement program studies, access audits, and member/provider satisfaction surveys.

• Collaborate with the appropriate data analytics team to plan and guide the analysis of required management and MSO reports.

• Collaborate with the IT department on improvements to the MSO software systems used by the UM and other teams.

• Oversee the response to clinically related grievances with appropriate team members, ensuring clinically accurate and timely responses according to timelines set in regulatory standards.

• Respond to all audit findings in a professional and timely manner.

• Oversee the UM Department budget, developing the annual budget in collaboration with supervisors and the medical team, ensuring fiscal responsibility in spending, and sound financial planning acumen.

• Collaborate with the CMO and Medical Officers to develop and present regular reports for the monthly UM Committee.

• Serve as the clinical management representative on the CHCN data team.

HIPAA Designated Access

“For the purposes of the job duties of this position, the person in this position requires access only to the following HIPAA protected information data sets”

X1. MSO MembershipX2. MSO ClaimsX3. MSO Referral/AuthX4. MSO Capitation

5. Data WarehouseX6. Chart Audit/QI

SUPERVISORY RESPONSIBILITIES

Yes

MINIMUM QUALIFICATIONS

Education & Experience

• Active and unencumbered RN license in the State of California

• 3+ years in Utilization Management / Quality Improvement in hospital, HMO, or IPA setting, preferably with the Medi-Cal Managed Care and Medicare Managed Care fields.

• 2+ years in health care delivery at hospital, clinic, facility, or provider’s office.

• Excellent written and verbal communication skills, including customer relationship management.

• 3+ years of staff supervision. Strong management experience is a requirement.

• Computer literacy. Knowledge of MSO software systems is a must.

• Sound decision-making skills for clinical and non-clinical issues.

• Ability to lead, train and coach others.

• Strong financial management skills.

• California driver’s license and reliable transportation required.

General CHCN Roles:

• Fosters an environment that promotes trust and cooperation among clients and staff.

• Enforces policies and procedures, including maintenance of client confidentiality, to ensure that the principles of CHCN are implemented.

• Accountable for participating in decision making processes and understanding the outcome(s).

• Understands the values and principles of CHCN and applies them in work responsibilities.

• Participates in outreach activities, agency advocacy, and serves on ad hoc committees, as requested.

• Attends UM Committee meetings and CHCN Board of Directors meetings, as required.

CERTIFICATES AND/OR LICENSES

RN

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and use hands to finger, handle, or feel. The employee is frequently required to talk or hear. The employee is frequently required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.

WORKING CONDITIONS AND ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly exposed to an inside/outside environment.

The Community Health Center Network is an Equal Opportunity Employer.