The Director of Utilization Management provides leadership, management, oversight, and assessment of all aspects of management and is responsible for managing overall utilization while ensuring delivery of essential services that address the total health care needs of The Health Plan members. The Director of UM works collaboratively with the Chief Medical Officer, Vice President of Medical Economics, Program Evaluation and Clinical Strategic Initiatives, Director of Case Management and Medical Directors, as well as other leaders to plan, organize, coordinate, develop the vision, perform implementation and measure the outcomes of all UM and A/G programs based on both governmental and non-governmental lines of business to ensure compliance to the requirements of all regulatory and accreditation bodies relevant to clinical management.

Required:

1. Registered Nurse with a minimum of 5 years clinical experience.
2. At least two years of experience should be in a management capacity.
3. Minimum of a Bachelor of Science degree in Nursing or willingness to obtain within two years of hire.
4. Holds active and unencumbered Ohio and West Virginia registered nurse license.
5. Minimum of five years in a managed care organization.

Desired:

1. Public speaking and excellent written communication skills, motivation and initiative, and ability to work independently.
2. Superior work ethic.
3. Experience in writing policies and procedures.
4. Proven leadership abilities.
5. Strong verbal, written, analytical, and interpersonal skills.
6. Flexible and able to multi-task, work in a fast-paced environment and adapt to changing processes.
7. Self-starter with strong entrepreneurial skills.
8. Certification in related area preferred, Certified Managed Care Nurse (CMCN).

Responsibilities:

1. Oversees medical and behavioral UM and A/G operations.
2. Provides direct supervision to the managers and supervisors.
3. Develops and monitors utilization management and behavioral health staff UM and A/G training program.
4. Participates on all clinical services and A/G committees.
5. Development and continual review and revision of all UM and A/G processes, policies, and procedures within the department.
6. Develops and enhances system of management reporting and metrics to be utilized for productivity, adherence, and outcome measurements to provide relevant information on overall effectiveness in UM and A/G areas.
7. Ensure department optimizes UM and A/G workflow efficiencies to meet company objectives.
8. Ensures that all medical and behavioral UM and A/G programs are delivered consistent with applicable internal policies and procedures as well as applicable CMS, BMS, NCQA or other regulatory agency requirements.
9. Ensures UM and A/G medical/behavioral health program compliance to quality outcomes.
10. e.g. STAR measures, HEDIS, CCIP, QIP and PIPs.
11. Responsible for medical management/behavioral health annual risk assessment related to UM and A/G.
12. Collaborates with the CMO, VP of Clinical Strategic Initiatives and Director of Clinical Programs on initiatives and interventions to ensure cross-functional and inter-departmental alignment with organizational goals.
13. Leads medical management and behavioral health UM integration with provider health systems.
14. Implements and monitors medical management, behavioral health, and third-party UM software programs.
15. Provides input into clinical services medical/behavioral evidence-based UM criteria.
16. Leads clinical services UM and A/G compliance and NCQA UM and A/G initiatives.
17. Interacts with government agencies, health systems, and employer groups to facilitate medical and behavioral UM and A/G integration.
18. Leads the BH and Medical transition of care teams and ensures workflow efficiency as well monitors the program for return on investment.