(Archived) Director of Utilization Management and Case Management

Job Summary:

Direct, manage and oversee all aspects of utilization and case management services, ensure efficiency of the workflow for team members, and ensure quality cost effectiveness.

Essential Duties and Responsibilities:

The Director of Utilization and Case Management is responsible for the overall strategy, operational performance and outcomes of the department’s activities. Develops, directs and monitors all Utilization Management (UM) and Case Management (CM) that serve all AMCM clients. Oversees and manages all UM and CM vendors with full responsibility for meeting organizational goals for UM and CM metrics and performance. Collaborates across the enterprise and with clients to ensure that objectives are aligned, business strategies are delivered and financial, compliance, and quality objectives are met.

Responsibilities:

• Directs all medical management utilization and case management and their related compliance functions (CMS, state regulations, URAC)
• Ensures 100% compliance with all federal, state, regulatory and contract requirements
• Develops, executes and evaluates work plan for area of responsibility
• Provides contract management for medical review criteria tool, utilization management, case management and vendors
• Prepares and analyzes monthly, quarterly and annual utilization reports, identifying over and underutilization patterns, case management outreach, enrollment and off boarding and proposes and implements effective interventions to address these UM and CM issues to meet national or client benchmarks
• Monitors monthly utilization and enrollment patterns; identifies outliers and puts in place program(s) with clients to address outliers
• Monitors and evaluates staff decision-making by analyzing quarterly reviews, overturned appeals, physician decision trends, patient identification, patient enrollment, and patient-related communications and then provides reports on performance and recommendations for needed improvements
• Develops all medical utilization review and case management policies, procedures and ensures annual review and revision
• Develops utilization review process and/or case management for new lines of business
• Collaborates with Medical Director (MD) or physician reviewers to resolve complex medical review and/or patient management issues, as needed
• Engages in on-going performance management with staff including coaching, mentoring, development and succession planning.
• Serves as organization consultant regarding medical review process, case management process, UM and CM regulations
• Participates in administrative budget development and monitoring for area of responsibility
• Identifies and recommends opportunities for improvement and implements process improvement activities
• Directs the development of new policies and/or modifications to existing ones in collaboration with the Benefits Manager, clients and other, as needed
• Serves as company representative for UM and CM
• Serves as UM and CM representative for all state, CMS and other regulatory entity requests as it relates to medical review decisions and authorization issues
• Other duties as assigned

Education and/or Experience:

• Current RN license.
• College degree and/or nursing diploma.
• 3 years utilization review experience.
• 3 years management/supervisory experience and demonstrated leadership/management skills in managed care.
• CCM Certification at hire or attained within 2 years of hire.
• Understanding of accreditation highly desired.

Knowledge and skills:

• Able to communicate with internal staff, external clients and healthcare providers.
• Conflict management/problem-solving skills.
• Strong and effective written, verbal and interpersonal communication skills.
• Able to work effectively with minimum supervision.
• Effective use of time management skills.
• Works well as a team player.
• Able to keep team focused at striving toward organization goals.
• Able to provide direction to team members.
• Highly organized self-starter.
• Extensive knowledge of insurance industry, benefit design and coverage issues.
• Able to manage multiple priorities.

Physical Demands:

• Lifting up to 25lbs. on occasion.

Work Environment:

• Office or Home office