RN Director of Utilization Management – Health Plan
Director of Utilization Management Job Summary:
The Director is responsible for Utilization Management, Review and Authorization processes and staff, including questions regarding procedures, training, and processes to assure compliance with policies and procedures.
Develops and implements effective and efficient standards, protocols and processes, reports and benchmarks that support and further enhances utilization management function and quality of healthcare services.
Ensure provision of appropriate care through prospective, concurrent and retrospective reviews of services.
Understand, promote and audit the principles of Utilization Management to facilitate the right care at the right time in the right setting.
Identify trends or issues in the Utilization Management process that requires further evaluation for their quality or utilization implications and bring these items to the attention of the Utilization Management Director.
Verify that any new process is communicated to the Utilization Management Staff and is followed via monthly audits of the staff’s production.
Director of Utilization Management Background:
Valid, unrestricted state Registered Nurse (R.N.) license, and a Bachelor’s Degree in Nursing (BSN) or related field; Master’s degree is a plus.
Certified in Utilization Management (CPUM/CPUR/CPHM) preferred
Around 4-5 years’ clinical nursing experience in a high acuity setting.
Roughly 7 years’ experience in Utilization Review/ Utilization Management for a Managed Care Organization (Health Plan, IPA, HMO, TPA, etc).
At least 5 years previous management experience, in roles of increasing responsibility, which included hiring and supervising nurses.
Familiar with California Medi-Cal and Medicare benefits, regulations and standards, as well as claims payment rules and their impact on care management processes.
Demonstrated knowledge of NCQA and CMS standards, Quality Improvement studies, HEDIS reporting.
Knowledge of healthcare & insurance industry current and future trends, in order to assess future market needs.
Skilled in influencing, leading and directing individuals in multiple functional areas.
Able to transform assignments from high-level objectives into independently established detailed goals.
Excellent verbal and written communication skills, as well as exceptional critical thinking skills.