Director, Utilization Management

FLSA Status: Exempt

Department: Health Services

Reports To: Vice President, Health Services

GENERAL DESCRIPTION OF POSITION

The Director of Utilization Management (UM) is responsible for the clinical and operational management of the Utilization Management Department activities including utilization management, concurrent review, prior authorization, care coordination, discharge planning, retrospective review, and claims support, including staff management to ensure that all administrative utilization management (UM) processes are performed in accordance with  applicable state and federal regulatory requirements, SCFHP policies and procedures and business requirements.

 ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily.

1. Manage and perform utilization management activates to ensure regulations, compliance, criteria, standards, and metrics as established by the Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), and Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and Healthcare Effectiveness Data and Information set (HEDIS) for Medi-Cal and Medicare lines of business.

2. Responsible for the development, design, implementation, and evaluation of the strategic plan for the UM department including the UM program, work plan, evaluation, and oversight of delegated UM functions.

3. Maintain accountability for utilization management functions to achieve business and clinical outcomes, meeting contract requirements, and supporting cross departmental initiatives with providers and members.

4. Manage effectiveness of UM coordinators and nurse’s review, coordination, and processing of prior authorization, concurrent review, discharge planning, and transitions of care activities including appeals, claims, provider disputes in accordance with established policy and standardized guidelines. 

5. Monitor and evaluation of under-/over utilization medical services and durable medical equipment for health outcomes analysis including but not limited to identifying gaps in care, cost effectiveness, vendor administration, and quality improvement opportunities through claims, encounter data, and prior authorization data.

6. Produce and submit regular reports and data analytics as required for, but not limited to, all medical services, compliance dashboard, regulatory requirements, productivity, clinical operations, benefit changes, implementation, and service quality monitoring.

7. Direct and participates in various meetings including the Utilization Management Committee, UM delegation oversight meetings, and additional interface with providers, delegates, vendors, hospitals, skilled nursing facilities, and community partners.

8. Assist Health Services Leadership and Medical Directors with activities to meet departmental and organization objectives and implementing action plans to address issues and improve key performance indicators and selected utilization/cost and quality outcomes.

9. Work cross functionally across departments to ensure timely implementation of benefit changes, regulatory requirements, and member and provider satisfaction.

10. Responsible for overseeing and maintaining UM contracts and Letter of Agreements (LOA).

11. Develop, coordinate and approve all departmental budget for the UM department. Assist with education of managers on the budget process and ensure appropriate monitoring of these areas is actionable.

12. Perform all job functions with integrity.  Provide timely internal and external customer service in cooperative, professional, and respectful manner.

13. Responsible for staffing ratios and projecting changes in staffing with new programs and member ratios.

14. Assist with system-wide initiatives as it relates to utilization of medical services and coordination of medical care including UM software/application implementations.

15. Attend off-site meetings or events as necessary.

16. Perform other related duties as required or assigned.

SUPERVISORY/MANAGEMENT RESPONSBILITIES

1. Carries out supervisory/management responsibilities in accordance with the organization’s policies, procedures, applicable regulations and laws.  Responsibilities include:

2. Recruiting, interviewing, and hiring.

3. Developing a high performing department culture and staff.  This includes setting the standard for staff/peers and motivating employees to maximize organi