Direct, coordinate and evaluate the efficiency and productivity of utilization management functions for physical health services and long‑term services and supports. Work closely with delegated entities, pharmacy, dental and other vendors to assure integration, oversight, and efficiency of UM processes.
Ensure compliance with all contract requirements, state and federal regulatory requirements, and all applicable accreditation standards; promote the development of a high‑quality team in collaboration with the broader clinical organization.
Integrate utilization management processes with care management and care delivery processes.
Work closely with the CMO and VPMA to develop and advance the UM program; lead and organize the ongoing evaluation of the utilization management program against quality and utilization benchmarks and targets. Identify opportunities for improvement; organize and manage outcome improvement initiatives.
Ensure staff selection, training, and performance monitoring.
Lead the Utilization Management team in managing and continuously improving UM program design, policies, procedures, workflows, and correspondence.
Support provider relations and provider contracting leaders in designing and implementing successful methods for working with providers. Ensure integration of UM functions with network strategy, vendor relationship management and claims processing; resolve provider‑related issues.
Direct the work of the UM team to ensure quality, inter‑rater reliability and standards are met in daily operations. Resolve and communicate UM issues and concerns and corrective action plan activities and reporting.
Provide expert input to Finance regarding patterns of utilization, cost and high‑cost cases.
Member of health plan QI Committee; co‑chair of health plan Utilization Management Committee.
Required Education
Bachelor's Degree or equivalent experience.
Desired Education
Master’s degree in Business or Health related field (preferred).
Required Licensing
Active RN license required.
Required Experience
7–10 years experience.
8–10 years of managed care operations experience, including a minimum five (5) years of leadership experience in Utilization Management (UM) or nursing leadership, with a minimum of two (2) years of leadership experience in UM.
Minimum three (3) years of management experience in a health plan environment with responsibility for managing the effective utilization of healthcare services, case/disease management, program development/evaluation, and quality improvement.
Minimum five (5) years of clinical experience in medical or behavioral health care delivery.
Required Knowledge, Skills & Abilities
Medicare and Medicaid managed care experience.
Demonstrated knowledge of federal and state regulations relevant to utilization management.
Demonstrated knowledge of health care industry trends, developments and issues.
Excellent oral and written communication and interpersonal skills such as influence, negotiation, persuasion, and conflict resolution.
Proven ability to influence and lead; strong team‑building skills, unquestioned integrity, confidence and stature to effectively address sensitive member issues.
Ability and desire to embrace and manage change; maintain high productivity and drive effectiveness amid ambiguity or stress.
Commitment to excellence and making a difference; results‑driven, improvement‑focused, action‑oriented leader who proactively seeks better ways.
Passion and commitment to positive and effective customer service focusing on members and internal customers; record of success in managing customer‑focused teams.
Business acumen and organizational awareness; strong analytical skills, excellent organizational skills and attention to detail.
Proven ability to influence course of action when others are directly accountable for outcomes.
Strong and effective communication skills, verbal and written; presence, confidence, influence and communication ability to represent the company to varied audiences.
Experience managing clinical services for Medicaid/Medicare patients.
Ability to lead and navigate large‑scale organizational projects and evolution.
Strong problem‑solving skills, attention to detail and ability to manage multiple tasks and priorities in a matrix environment.
Competent in working with vulnerable and diverse populations.
Ability to work under pressure and meet deadlines.