Utilization Management Director - Remote - State Of Oh

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us and start doing your life's best work.(sm)

If you are located in the state of Ohio, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Develop written policies and procedures regarding authorization of services and monitor to ensure that these are followed
• Ensure MCO Notices of Adverse Action are provided in accordance with 42 CFR 438.404
• Oversee the day-to-day operational activities of the Utilization Management Program in accordance with state guidelines
• Liaison with the Ohio Department of Medicaid (ODM), the OhioRISE Plan, the single pharmacy benefits manager (SPBM) and other ODM-contracted managed care organizations on utilization management health activities as directed by the Chief Medical Officer (CMO)
• Ensure that the utilization management program is compliant with MHPAEA assessments
• Ensure timely updates of United Healthcare clinical coverage determination guidelines consistent with United Healthcare Community Plan of Ohio, Inc. Guidelines and Ohio Department of Medicaid requirements
• Coordinate extensively with the Ohio Department of Medicaid Regulator on policy and procedure for UnitedHealthcare’s Utilization Management Program as directed by the Chief Medical Officer (CMO)
• Running full-scale tests of change to improve utilization efficiency and performance using quality improvement science to reduce the overall rate of inappropriate denials
• Oversee the plan’s implementation and evaluation of utilization management based on a deep understanding utilization management principle and practice

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Experience with running / managing utilization management efforts
• Proven ability to influence and work with all levels of internal and external stakeholders/resources to move quality improvement projects and programs forward and overcome any challenges
• Advanced to expert level of proficiency with MS Project, Excel, Visio, PowerPoint, TEAMS, and SharePoint
• Solid knowledge of health insurance industry utilization trends, reimbursement methods, and evolving accountable care and payment models
• 5+ years of progressively responsible professional experience in utilization management, service coordination, ambulatory care, community public health, case, or care management, or coordinating care across multiple setting with multiple providers
• Certified Professional in Healthcare Quality Certification (CPHQ®) by the NAHQ and/or CHCQM® by the American Board of Quality Assurance and Utilization Review Providers or Lean background strongly preferred. If not certified, must be willing to obtain coursework within 6 months of hire and certification within 12 months of hire or obtain equivalent training and/or certification
• Experience in actively applying or overseeing the application of science-based quality improvement methods to reduce health disparities
• Experience with cost-benefit analysis, quality assurance and continuous quality improvement processes
• Experience pertinent to the complex patient population(s) being managed
• Ability to be full-time and based (working and reside) in the state of Ohio
• 3+ years of experience providing direct behavioral health care coordination or oversight for children and adolescents with complex behavioral health needs or equivalent experience
• Experience in managed care and value-based programs
• Complex utilization management experience
• Ohio-licensed registered nurse, APRN, licensed independent behavioral health clinician (MD, DO, RN with advanced practice registered nurse (APRN) licensure, psychologist, licensed independent social worker (LISW), professional clinical counselor (LPSS) or a physician with a current unencumbered license through the Ohio State Medical Board with experience in the activities of utilization management, in accordance with 42 CFR 438.210

Preferred Qualifications:

• Experience working with Medicare, Medicaid and DSNP populations and the utilization nuances of each patient population
• Well-versed in with extensive experience with key-driver diagrams, flowcharts, check sheets, Pareto diagrams, cause and effect diagrams, histograms, scatter diagrams, run and control charts
• Hands-on experience and mastery of Quality Improvement principles
• Experience in quality management and quality improvement as specified in 42 CFR 438.206 through 438.370
• Training / Certification in quality improvement science
• Tableau-BI experience
• Master’s degree or other advanced degree in nursing, social work, health services research, health policy, information technology, or other relevant field
• Project management or active project participation experience
• Healthcare and utilization management experience at the managed care plan or provider level

Skills and Abilities:

• Comfortable working through ambiguity toward clarity around data specifications and sources
• Active management of multiple utilization management groups
• Collaborative spirit - internal and external to the organization
• Flexibility in daily work schedule and task assignment
• Demonstrated ability to analyze metrics, summarize key business learning, and translate into tactical plans and report to executive level management
• Maintain a patient-focus

Essential Characteristics:

• Ability to travel on an as-needed basis
• Ability to articulate policy and procedure to external stakeholders
• Ability to work well independently

Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work.(sm)

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.