About the role
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 findings * Communication skills, verbal and written, needed to convey information clearly and consistently * Interpersonal skills necessary to develop and maintain a wide variety of cooperative working relationships
Salary: $160,000.00/Annually