Integra’s Utilization Management (UM) division is looking for an experienced individual to direct the clinical and non-clinical utilization management teams for a managed care organization. This individual will play a key role in delivering UM to our health plan clients, growing our UM business, and working with the organization to operationalize our UM program.
JOB QUALIFICATIONS: KNOWLEDGE/SKILLS/ABILITIES
The Director of Utilization Management’s responsibilities include but are not limited to: Prepare and maintain Utilization Review Plan policies and procedures
Obtain or maintain certification or license in states when performing Utilization Review
Work with Chief Medical Director to establish, adopt, and review UM benefit and medical necessity decision-making criteria
Manage UM Department, clinical and non-clinical staff, to ensure timely review of prior authorizations and appeals
Responsible for UM-related quality improvement activities, including conducting audits to ensure consistent application of medical criteria, evaluating program for improvement opportunities and annual IRR testing
Communicate and work with company executives and management to ensure alignment of UM program with departments and corporate initiatives
Participate on Quality Improvement Committee and UM Committee to oversee clinical oversight of UM Department
Work in conjunction with Account Managers and external liaison for clients to ensure program meets contractual delegated activities and performance requirements
As needed, represent the UM team in support of client-facing efforts such as business development and/or business review activities.
Help consult on existing and/or prospective client UM programs
Participate in technology related activities and implement solutions across UM Department
Oversee and execute the workplan to maintain NCQA certification
Build and manage the administrative and clinical resources to ensure the UR program functions efficiently and effectively, meeting all internal, legal, regulatory, and/or certification standards
Build and maintain a staffing model that is flexible and appropriate to scale as the business scales
Manage internal policies and procedures and workflows to ensure compliance, effectiveness, and best in class clinical operations
Owner of the third party technology and configuration of medical management software to ensure optimal operation
Responsible for day-to-day team management to ensure on-time, on-budget delivery of all operations · As needed, represent the UM team in support of client-facing efforts such as business development and/or business review activities
Help consult on existing and/or prospective client UM programs
WHAT WILL YOU LEARN IN THE FIRST 6 MONTHS?
In the first six months you will learn the function of the UM department within the organization and be fully integrated in your position, company, and team
You will have a full and complete understanding of our metric requirements and reporting capabilities
You will understand your role and responsibilities, to foster excellence in team performance
You will develop team goals and monitor progress, as you build relationships with your team to encourage and understand their needs and abilities
During this time, you will set measurable goals for personal development and growth
WHAT WILL YOU ACHIEVE IN THE FIRST 12 MONTHS?
You will create a people first approach to your team, easily identifying the strengths and weakness of each team member and how to best support them
You will be contributing your skills and knowledge to meet your department’s metrics and goals
EXPERIENCE:
Bachelor’s degree in area of specialty, preferred
Minimum of 10 years of UM management experience in a managed care setting
Experience with UM NCQA or URAC certification/accreditation
Experience with leading and managing teams of clinical and non-clinical staff
Analytical ability and clinical knowledge in order to assess medical records, identify trends, and report…