Showe and Associates LLC
Executive Recruiting Services for the Managed Healthcare Industry

Director of Utilization Management - Health Plan

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Location
Bridgewater, MA
Job Type
Direct Hire
Date
Jul 30, 2019
Job ID
2674833
Nationally recognized integrated health plan seeks a Director of Utilization Management to lead a CM / UM team in Southeastern Massachusetts.  The Director of Utilization Management will:

 


  • Manage criteria-based reviews of care, clinical appeals regarding medical necessity, and the interaction with claims payment policies and processes.
  • Support goals, contracts, and accreditation requirements of health plan by conducting reviews of clinical interactions and clinical documentation including reviews of case management, utilization management, vendor, and provider records.
  • Collaborate with local and national leaders including quality improvement, analytics, finance, network, ensuring a comprehensive approach to managing quality of care, service, and cost of care.
  • Provides expert input to finance regarding patterns of utilization and cost and high cost cases.
  • Manages a call center team and case management team

 

Requirements:  

 


  • RN, state of Massachusetts, BSN preferred
  • 5+ years experience in case management / utilization management 
  • 3+ years UM leadership including mentoring and training staff
  • A background that includes strong clinical work, experience in managed care and managing a call center team
  • A depth of experience and strong understanding of managed care referral requirements
  • A strong familiarization with Medicare guidelines and authorization processes
  • Utilization management experience in an outpatient clinical environment.  
  • Knowledge of ambulatory healthcare delivery and management. 
  • Working knowledge of NCQA, and health plan requirements related to utilization management. 
  • A strong understanding of ambulatory healthcare delivery and management
  • Demonstrated knowledge of prospective authorization process and workflow
  • A track record of accomplishment in handling multiple competing priorities
  • Working knowledge of Microsoft Office Suite, including Windows
  • High energy with demonstrated accomplishment in working independently and in a team environment
  • Experience overseeing contractual performance standards
  • Strong background in the reporting and analysis of managed care utilization data
  • Strong analytical skills
  • A track record of accomplishment managing UM / CM teams
  • Strong communications and leadership skills