Director of Utilization Management and Complex Care Management

Job Summary

The Director of Utilization Management and Complex Care Management provides leadership to and is responsible for the transitional care management and complex care management teams. These teams leverage utilization management clinical criteria (MCG), best in class transitional care management, and proven whole-person complex care management pathways to:

1. Engage and build trust with our members
2. Deploy member-centric interventions to provide best in class clinical outcomes
3. Ensure appropriate facility/hospital length of stay
4. Reduce readmissions and overall bed days

This integral role combines strategic planning with hands-on operational oversight to meet clinical, financial, quality, and contractual success. Success in this role is measured by meeting and/or exceeding KPI targets around member engagement, Admissions, Readmissions, ED visits/1000, SNF days/1000, and length of stay.

The role will need to work well within a matrixed integrated management structure including National Shared Services leaders and Market Leadership.

 

Duties and Responsibilities

 

• Manage and lead an integrated care team to reduce total cost of care and appropriately reduce admissions/1000, readmissions/1000, ED visits/1000, SNF days/1000, and length of stay.
• Use data analytics to monitor team/contractual performance and create action to improve utilization, clinical outcomes, quality metrics, and member satisfaction. Ability to leverage reporting to create action and drive key value outcomes.
• Establish and maintain strong collaborative external relationships and partnerships: hospitals, skilled nursing facilities, home health agencies, and community-based organizations (housing food), community providers, and specialists.
  • Hospital care management, discharge planning teams and facility leadership highlighted as critically important.
  • Leverage SDoH interventions
  • Lead collaborative rounds with health plan partners
• Maintain strong relationships with our health plan partners and ability to lead utilization management rounds with plan partners.
• Establish department goals, manage clinical financial risk, and address operational issues to ensure performance meets or exceeds contractual objectives.
• Serve as an SME in complex care, care management, and therapeutic approaches, promoting best practices in member care through training and evidence-based guidance.
• Address complex needs of populations facing medical, behavioral, and socioeconomic barriers using data-driven, empathetic interventions, such as motivational interviewing and trauma-informed care.

 

• Manage caseloads to ensure follow-up, timely documentation, and regulatory compliance.
• Lead and manage a diverse care management team, including registered nurses, social workers, and
• Oversee staff development and adherence to best in class care standards, including person-centered integrated care planning, SMART goals, and NCQA/regulatory documentation protocols.
• Conduct performance activities such as case audits, coaching, and training to maintain compliance with quality and accreditation standards.
• Oversee hiring, onboarding, and training processes for new team members, aligning team growth with organizational objectives.
• Engage team members through regular meetings, team-building activities, and virtual or in-person morale-building efforts. Includes have routine 1:1 meeting with the team.
• Responsible for employee engagement and staff turnover rates of their areas of responsibility.
• Host interdisciplinary care team (ICT) meetings, ensuring follow-up on action items to enhance member outcomes.
• If warranted, will direct a lead role who will be a subject matter expert with departments workflows, tools, and processes.
• Identify low-performing staff or processes, implementing performance improvement plans as needed.

Stakeholder Engagement and Representation

• Represent the department in senior management and external partner meetings, aligning operations with organizational strategy and fostering stakeholder relationships.
• Support customer resolution efforts, coaching team leaders on best practices and managing escalated cases as necessary.