We are recruiting for a motivated Senior Director, Health Plan Utilization Management (* Hybrid Work Schedule *) to join our team!

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Department

Managed Care Administration

*Hybrid Work Schedule

Job Summary

The Senior Director of Health Plan Utilization Management is a senior leader for the Denver Health Medical Plan (DHMP) with responsibility for providing strategic and operational leadership for all utilization management functions across the organization. This area has unique regulatory and contractual compliance requirements for each line of business. This role is responsible for ensuring clinically appropriate, cost-effective, and regulatory-compliant medical necessity determinations while supporting high-quality member outcomes and provider collaboration. The Senior Director partners closely with Operations, Network Management, Quality, Compliance, and Finance to align utilization management strategy with organizational goals. In this capacity, the Senior Director oversees multiple teams performing this work. The Director reports to the DHMP Chief Medical Officer and collaborates closely with them to develop, update and implement the DHMP Utilization Management vision and strategy.

Essential Functions:

• Assures that all staff are appropriately trained on all relevant software programs and applications necessary to perform their job functions. (10%)
• Participates in presentation of reports to the Operations Team, DHMP Board of Directors, and other bodies, as required. (10%)
• Attends and participates in Quality Management Committee, DHMP Operations Team meetings, Utilization Management Committee, enterprise Care Coordination meetings and other related meetings and activities as required. (10%)
• Serves as an issue-related or escalation liaison between Utilization Management and other departments and/or agencies both within DH, contractors and/or plan members. (10%)
• Oversees the maintenance, development, implementation, and continuous improvement of UM policies and procedures and management of information systems to accomplish UM goals for all contracted populations. (10%)
• Develops, analyzes, and presents reports on productivity, quality and outcomes. (10%)
• Ensures DHMP can provide documentation of compliance with contractual and regulatory requirements prior to audit by the State, CMS, DOI, etc. (10%)
• Develops, implements, and evaluates formal educational activities and follows up on issues identified through educational activities. Brings new knowledge to staff meetings. (10%)
• Works closely with DHMP Compliance Officer to ensure all DHMP lines of business operational performance meets or exceeds regulatory requirements including, but not limited to, policies and procedures reporting. Acts as a voting member of the DHMP Compliance Committee. (10%)
• Ensures routine and ad hoc reporting available which may include utilization data by setting (inpatient, outpatient, and Pharmacy), or other special projects supporting the overall goals of DHMP. (10%)

Education:

• Master's degree required
• Graduation from an accredited educational program for Nursing or Physician’s Assistants required

Work Experience:

• Seven years of experience in administration in managed care, health plan administration or healthcare provider organizations required AND
• Minimum of five years of supervisory and management experience required AND
• 1-3 years Health Plan or healthcare experience with various lines of business including Medicare, Medicaid, CHP, Exchange and/or Commercial Plans required AND
• 1-3 years Experience in managing vendors required required

Licenses:
Knowledge, Skills and Abilities:

• Knowledge of regulatory and accreditation standards for health plan or healthcare operations required.
• Strong program development, analysis, and evaluation skills required.
• Demonstrated excellence in managing people and processes.
• Strong leadership skills with ability to engage multidisciplinary clinical and non-clinical teams to solve complex problems.
• Strong knowledge and experience in utilization principles, concepts, and strategies preferred.
• Ability to develop and maintain effective relationships with internal and external stakeholders.

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