POSITION TITLE: Director of Utilization Management
DEPARTMENT: Utilization Management 310
REPORTS TO: Chief Health Services Officer
FLSA STATUS: Exempt
The Director of Utilization Management (UM) provides comprehensive oversight of the Utilization Review process under the Knox Keene license and Department of Health Care Services contract. The position integrates and coordinates services using continuous quality improvement initiatives to promote positive member outcomes. Frequent executive level reporting and tracking on department and individual team productivity is essential. The Director of UM assesses needs, plans, communicates, designs services and strategies to forward the mission and serve member needs. The Director provides strategic leadership, development, and supervision to utilization review department, provides inter-professional collaboration with facility-based case managers and discharge planners, and coordinates with all aspects of the Kern Health Systems functions, including Claims and Member Service, to provide guidance on complex Authorizations, Referrals, Denials and Appeals.
Under the direction of the Chief Health Services Officer, and in collaboration with the Chief Medical Officer, the Director of UM assists in coordinating clinical functions and programs which effectuate and support KHS medical policy according to contractual requirements, and in developing and implementing new clinical programs to manage costs and ensure quality care delivery. The position will be an essential contributor to the development, implementation, and monitoring of the Population Health strategy and ongoing process improvement.
- Oversees formal utilization and network coordination services. Provides operational oversight and recommends corrective action for all shared services
- Manages the UM results, including referral management; acute, SNF and Rehab admissions
- Continually creates and implements strategies to improve organizational and UM Departments performance
- Participates in contracted provider network meetings to enhance communication and continuity of member care services
- Has management responsibility as assigned for the key Medical Management Programs, Coordinated Care, DME, Ancillary services, and Pharmaceutical collaboration
- Participates in determination of department’s goals and objectives, setting organizational structure, staffing, and space planning
- Participates in recruitment, retention, and training of UM Management staff.
- Acts as a resource to other departments in regard to Case Management, Disease Management,
Health Education, Quality Improvement, Compliance, Provider Network Management, and Claims
- Collaborates with Executive leadership of Medical Management, Medical Directors, UM Management, and other staff as well as other departmental peers
- Program Development, Implementation and Evaluation
- Conduct needs assessment including development of methods for determining potential patient enrollment, medical literature review, analysis of pre-program utilization and return on investment
- Development of Program to include establishment of policies and procedures, enrollment strategies, member and physician materials, and measurements of program outcome
- Development of clinical practice guidelines
- Evaluate staff educational needs and coordinate training
- Analytical ability for problem identification and assessment and evaluation of data/statistics obtained from an on-going review process.
- Knowledge of Milliman Care Guidelines (MCG), InterQual Criteria, MCAL and CMS Criteria
- Knowledge of managed care health plans operations and HIPAA guidelines
- Experience and knowledge in intermediate computer skills (i.e. Microsoft Word, Excel)
- Leads and participates in cross functional corporate teams which design and implement new population management programs
- Develops and implements process and program redesigns.
- Leads multiple teams of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources.
- Manage appeals, grievance, disputes, and claims reviews for services under review.
- Ability to utilize multiple technology systems for documentation and coordination of services
- Ensures adherence to all contract, regulatory and accreditation requirements.
- Develops short/long-term objectives and monitors processes and procedures to ensure consistency with the enterprise and compliance with state and federal regulations.
- Collaborates with community partners to resolve issues or find solutions.
- Manages budget and special projects.
- Hires, trains, coaches, counsels, and evaluates performance of direct reports.
- Serves in a supportive role as a member of the Physician’s Advisory, Quality Improvement and Utilization Management, Compliance, Fraud, Waste and Abuse, Delegated Oversight, and Pharmacy & Therapeutics Committees.
- Responsible for detailed utilization analysis and benchmarking.
- Encourages staff in growth opportunities, in-services, seminars, etc.
- Directs, coordinates and evaluates efficiency and productivity of utilization management functions for physical and behavioral health services (mental health and applied behavioral analysis).
- Develops a comprehensive orientation program for all new employees in the Health Services Department.
- Establishes and monitors a after-hours clinical triage programs to provide assistance to members in obtaining appropriate medical care outside standard office hours.
- Collaborates with network leaders to design and operationalize successful methods for working with hospitals, home health, and other ancillary services.
- Assist in the review and updating of Policy and Procedures
- Coordinates with Health Services leadership in identifying inappropriate utilization of services for over and underutilization.
- Coordinates with Provider Network Management on referral and inpatient activity where provider behavior needs to be addressed or provider feedback/input is required.
- Reviews and approves Notice of Action (NOA) letters and Letters of Agreement (LOA) for non-contracted providers and facilities, ensuring appropriate alternatives have been considered for contracted services.
- Evaluates, assesses, coordinates, and initiates processes towards NCQA accreditation in the areas of Utilization Management.
- Interviews, selects, trains, develop, and evaluate staff; provides input to management regarding disciplinary issues, including Performance Improvement Plans (PIP).
- Performs other job-related duties as required.
- Adheres to all company policies and procedures relative to employment and job responsibilities.
Core Competencies/Knowledge & Skill Requirement
- Strong knowledge of the principles, techniques and practice of public and community health education, including the understanding of the theory and ability to apply knowledge of the basis of human behavior, the process of education, motivation and group work, and the relationships of cultural patters of human behavior;
- Demonstrated knowledge of and skill in protocols of Disease Management;
- Strong knowledge of common patient disease processes and usual methods of treating them;
- Knowledge of medical terminology and commonly used equipment;
- Knowledge of ICD9 and/or CPT coding;
- Ability to supervise and mentor staff, analyze situations independently and make appropriate decisions;
- Ability to prepare written reports and maintain accurate records;
- Strong analytical, assessment and problem-solving skills with intermediate negotiation skills;
- Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individuals at all levels both inside and outside of KHS;
- Ability to use tact and diplomacy to diffuse emotional situations;
- Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards;
- Advanced computer skills that include MS Office products;
- Demonstrated ability to commit to and facilitate an atmosphere of collaboration and teamwork;
- Demonstrate ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, KHS business or employee information and make no disclosure of such information except as required in the conduct of business.
- Demonstrated ability to multi-task in an interrupt-driven environment and complete assignments on a timely basis;
- Strong attention to detail; work accurately and at a reasonable rate of speed.
- Bachelors (BSN) from an accredited college or University in Nursing (BSN) or other relevant health care field required. Master’s degree (MSN) preferred.
- Possession of Current, active and unrestricted RN license for the state of California
- Minimum of Five (5) years of management level experience in Utilization Management in a managed care environment or healthcare industry.
- Minimum of five (5) years’ clinical experience in Utilization Review or Case Management in a Health Plan or similar payer/provider setting (Hospital, Managed Care network, etc.) and with community-based programs.
Knowledge of: Utilization Management in a managed care environment; basic procedures utilized in claims processing in a managed care environment; medical reimbursement methodologies; supervisory and training techniques. Thorough knowledge of regulations and requirements related to utilization management (UM) Experience with QA/QI and program development/process improvement
Ability to: Adapt to a rapidly evolving work environment; work independently and manage multi-task responsibilities; communicate with a variety of personnel and providers; establish and maintain appropriate quality improvement and utilization management programs; make decisions within a managed care environment; prepare a variety of statistical and narrative reports; effectively supervise and train staff.
Other: Possession of valid driver’s license and proof of State required auto liability insurance. Required Travel Up to 20% Bilingual (English/Spanish) preferred.
The position purpose, job duties, responsibilities, competencies skills, essential functions, education factors and the requirements and conditions listed in this job description are representative only and not exclusive of the tasks that an employee may be required to perform. Kern Health Systems reserves the right to revise this job description at any time, and to require employees to perform other tasks as circumstances or condition of its business considerations or work environment change.