Corporate Director, Utilization Management Operations, REMOTE

Responsibilities:

Under the general direction of the VP UM Operations, the Corporate Director of Utilization Management (UM) Operations is responsible for the successful, ongoing development, refinement, implementation, measurement, ongoing quality improvement and effectiveness of the enterprise Utilization Management Program.; This leader will be responsible for new business RFPs and implementations. The Director UM Operations will identify opportunities for next best actions to improve processes and lower costs.;; This leader will apply expertise in developing and utilizing key performance indicators to identify and investigate complex problems in various health care domains across several problem spaces. This leader will also deliver results on high-impact projects collaborating with various stake holders.;;;

This includes the following:

• Concurrent review of acute, skilled and rehabilitation inpatient episodes, prior authorization of elective, inpatient and outpatient procedures and durable medical equipment requiring pre-certification and processing of medical necessity appeals.;


• Functional support to the each market’s Network Management, Informatics, Information Solutions, Quality Management, Care Coordination, and Public Affairs departments to integrate UM initiatives and goals with organizational programs.;;;


• Active role in the dissemination of best practices throughout the AmeriHealth Family of Companies and assists with new business opportunities and implementation.;


• Ensures consistency and conformance to all applicable standards and regulations


• Ensures UM operational processes are meeting contractual time lines and SLEA


• Oversee effective use of prior authorizations, policies, and benefits to ensure consistent, effective and efficient delivery to members while meeting regulations and internal financial objectives


• Review periodic reports (financial/utilization/services) to analyze trends, identify opportunities and ensure consistent deployment of;accurate data according to established polices & procedures across enterprise and market teams


• Initiates organizational and system changes to improve departmental staffing efficiency and effectiveness, and program outcomes within the markets


• Monitors performance metrics across LOBs and assures that appropriate action is taken to address performance opportunities consistent with enterprise policies.;


• Identify long-range, competitive strategies for UM, policy, and member benefits


• Partner with medical directors, enterprise, and market leaders in the development of best practices and shared learnings


• Maintains consistent program implementation and staffing across all LOBs.

Education/ Experience:

• Bachelor’s Degree in a healthcare related field.


• Registered Nurse preferred.


• 5 to 10 years clinical experience leading Utilization Management teams.;

;

;