Director, Utilization Management (RN license)
Location: Orange, California US
Job Number: 1081
Position Title: Director, Utilization Management
The Director of Utilization Management (UM) is responsible for developing and implementing an industry leading UM program that is consistent with the philosophies of Alignment Healthcare. This critical role is responsible for overseeing a valued team of UM nurse and coordinator staff, while promoting quality care outcomes.
- Promotes a provider and member-friendly, customer service oriented philosophy within the Utilization Management department
- Ensures timely ongoing authorization requests review in all Alignment HealthCare markets.
- Ensures appropriate usage of resources to facilitate the UM process
- Identifies opportunities for process improvements necessary to facilitate department functions
- Handles escalated cases either internally or those referred by contracted providers.
- Works closely with Member Services Director and tracks continuity of care issues identified through the enrollment process, and resolves when identified.
- Works closely with market Leaders and Regional Medical Officers (RMO) to manage business need for UM operations
- Ensures that all department activities follow the NCQA, URAC, and general accreditation standards as well as state and federal regulatory requirements
- Evaluates compliance policies and procedures and analyze/recommend enhancements
- Ensures compliance within applicable state program guidelines
- Ensures compliance with the NOMNC/DENC processes HHA, or CORF services
- Maintains confidentiality of information between and among health care professionals.
- Assists with the review and development of new protocols, procedures and guidelines.
- Participates in onsite and webinar CMS/health plan audits as subject matter expert on UM policies, standards and compliance for UM operations.
- Responds timely to corrective action plans and all follow-up activity.
- Works closely with all clinical personnel making UM decision to ensure compliance with regulatory and health plan guidance and citations.
- Works closely with market leadership on UM initiatives to ensure regulatory and accreditation compliance.
- Assists with ensuring consistent data collection from UM staff that is used to assist the company in achieving corporate goals, to improve monitoring and reporting to meet external requirements
- Manages the oversight of the UM Dashboard, ensuring timely submission to the Executive Management
- Responsible for oversight of the data validation and timely report submission required for AHP monthly, quarterly and annual reports.
- Collecting, evaluating and reporting data and activities as applicable within the UM Monthly Reports, NOMNC (HHA or CORF), OMT, Medical Services Committee Reports (MSC)
- Educates staff as necessary to ensure consistent performance and adhere to standards
- Develops staff to ensure smooth operations in utilization management and provides educational
- training on issues related to utilization management.
Develops training material for UM staff to ensure:
- Clinical staff are utilizing Alignment Health Care-approved Clinical Criteria.
- All staff are using CMS approved letter templates when communicating UM decisions / actions to members.
- All staff are using CMS/Alignment Health Care approved language in Member communication.
- All staff are managing and transferring members according to the Continuity of Care requirements
- All staff are documenting according to internal processes as outlined in Department policies, protocols and standard operating procedures
- Current license to practice as an LPN or RN
- Master’s degree in nursing, health care administration, or related field is preferred
- 5 years or more of experience in an Utilization Management leadership role
- Previous management and supervisory experience
- A strong internal drive for process improvement
This individual supervises the UM Coordinator(s) and nurse(s), as applicable.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Education and/or Experience: Successful completion of an accredited Registered Nursing Program; two to three years related experience in a managed care setting
- Certificates, Licenses, Registrations: Current, Active and Unrestricted Registered Nursing License preferred
- Other Qualifications:
- Knowledge of Medicare Managed Care Plans
- Computer Skills: Word, Excel, Microsoft Outlook
- Experience with the application of UM Criteria (i.e., Milliman Care Guidelines, Apollo, CMS National and Local Coverage Determinations, )
- 3+ years of utilization management/quality improvement experience
- Working knowledge and understanding of quality improvement concepts
- Previous experience as a lead in a functional area or managing cross functional teams on large scale projects
Skills and Abilities
- Language Skills: Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
- Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly
- Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution;
- Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability
- Report Analysis Skills: Comprehend and analyze statistical
- Leadership/Management Skills: Ability to successfully lead UM team and cross functionally through a matrix organization structure.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or
- The employee is frequently required to reach with hands and
- The employee is occasionally required to climb or balance and stoop, or
- The employee must occasionally lift and/or move up to 20
- Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Location City: Orange
Location State: California
Community / Marketing Title: Director, Utilization Management (RN license)
Who is Alignment Healthcare?
- Socially responsible
- Technologically enabled
- Concierge care
- Servant leadership
We are dedicated to transforming the complex and confusing process of medical treatment in the United States so that every link in the health care continuum becomes more efficient, productive, and effective. We built a team of people who want to make a difference. Come join the team that is changing health care one person at a time.
We believe that great work comes from people who are inspired to be their best. We invite you to explore our wide variety of roles based on your unique experience.
EEO Employer Verbiage:
Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.
If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact email@example.com.