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Senior Director of Utilization Management

Job Ref: 93120
Location: Downtown NYC

In Person: 2 days per week

Salary Range: $180,000.00 – $200,000.00

About Client

Cure Staffing, Inc, DBA Cure the Executive Edge has partnered up with one of NYC’s most prevalent and prestigious insurance providers. Our client provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, and network including primary care providers, specialists and participating clinics. Over the last three decades, our client has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life and we are excited to help them accomplish this goal. We are seeking qualified, appropriately skilled professionals who can provide reliable and professional support. All candidates must have education, experience, licenses, and certifications that are applicable and appropriate to the level of this position.

Position Overview

The Senior Director of Utilization Management is responsible for providing hands-on operational expertise and leadership to the company’s Utilization Management services. In addition to overseeing all aspects of utilization management pertaining to medical services, the Senior Director of Utilization Management will actively collaborate with leaders from other departments within Medical Management that conduct utilization management activities (e.g., Behavioral Health, Pharmacy) to ensure overall operational effectiveness. The Senior Director of Utilization Management will directly report to the Vice President of Clinical Services to help foster efficiency, quality, and innovation for the areas of responsibility. The Senior Director of Utilization Management will periodically review operational processes and workflows to ensure compliance with regulatory requirement and administered in a way this promotes efficiencies. The Senior Director of Utilization Management collaborates with departments outside of Medical Management to enhance the organization’s utilization management capabilities and facilitate successful execution. Designing, implementing, and administering industry best practices for the areas of responsibility, and instilling continuous process improvement across all teams and services is critical for this position’s success.

Responsibilities also include program planning, design, implementation, analytics, report preparation, supervision, staff development, leading program to accreditation and full compliance with regulatory requirements, and productive interaction with all departments, Providers, Community Based Organizations and Business, as well as members.

Job Description

The Senior Director of Utilization Management is accountable for leadership and budgetary oversight; policy and procedure administration; and compliance as it applies to the functions with the scope of the position, which include but not limited to:

  • Meet department goals by coordinating business activities in the areas of budget, personnel, and space management of direct reports.
  • Translate and reinforce the organization’s strategic priorities, targets, and objectives across all areas of responsibility.
  • Align roles and responsibilities with the mission, vision, and values.
  • Develop, review, implement, and oversee effective administration of policies and procedures in accordance with contract compliance as well as regulatory and accreditation requirements.
  • Oversees and evaluate the activities and effectiveness of Utilization Management activities.
  • Take action on priority objectives and assign resources needed to achieve results.
  • Build a high-functioning team that meets all operating goals, including quality, efficacy and cost of health care, administrative expense, customer service, performance improvement, regulatory requirement satisfaction, and staff engagement.
  • Monitor staffing patterns to meet Utilization Management functional needs to assure clinical input to the decisions made in the process of Utilization Review.
  • Provide day to day oversight of Team Leaders and UM Managers activities to ensure utilization review activities are conducted timely meeting NYS DOH and CMS regulatory standards.
  • Monitor operations and implement strategies that promote compliance with regulatory standards.
  • Provide clinical support and education as necessary to all of the plan medical management staff.
  • Provide mentoring and coaching to direct reports to build and strengthen Utilization Management effectiveness.
  • Ensure regular departmental staff meetings are conducted and action items and follow-up issues are completed.
  • Partner with other Departments to develop, implement, and monitor system-wide performance improvement initiatives for Utilization Management measures.
  • Work with all disciplines to maintain quality patient care and meet company contractual obligations, professional standards, and accreditation requirements.
  • Represent the health plan at regulatory meetings held by the New York State Department of Health, the New York City Department of Health and Mental Hygiene, and managed care trade organizational meetings as necessary.
  • Evaluate effectiveness through analysis of defined metrics and recommend enhancements and/or improvements to facilitate consistent, cost-effective, and proactive management.
  • Identify and recommend opportunities for cost savings while improving the quality of care across the continuum.
  • Monitor and manage vendor contracts and relationships.
  • Assist the Vice President of Clinical Services in developing, analyzing, and maintaining key performance indicators which could impact staffing levels, quality of services, revenues, or expenses.
  • Organize workflows, assign priorities, devise strategies, and utilize technology to achieve desired outcomes.
  • Assist the Vice President of Clinical Services to ensure that strategic plans, goals, and financial targets are implemented within each business unit to support the growth and fiscal solvency of the plan.
  • Develop and implement management processes centered on accountability and effectiveness.
  • Develop and implement robust performance and operational metrics for all processes and products, to include outcome metrics for specific products.
  • Identify, design, and implement process improvement opportunities that support utilization management effectiveness.
  • Other duties as assigned by the Vice President of Clinical Services or Plan leadership.

Minimum Qualifications

  • Bachelor’s Degree required
  • Requires a minimum of 8-10 years of management experience with a health plan
  • Requires broad clinical knowledge with good clinical background, analytical and decision-making skills
  • Requires knowledge of evidence-based guideline tools (InterQual, Milliman) for utilization management
  • Successful experience that includes budget management
  • Proven experience managing operation centers specifically in the managed care environment
  • 5+ years’ experience managing operations teams in a large, complex environment
  • Experience with Federal, State, and accreditation organizations
  • Experience with managed care audits and reviews required
  • Demonstrated experience with writing and implementing program level policy and procedures required
  • Experience applying medical management treatment guideline, such as InterQual, Milliman, or other practical management guidelines required
  • Experience with Change and Organization Management. Should possess performance-driven management style
  • Ability to implement performance matrix and outcomes matrix
  • In-depth knowledge of all aspects of managed care medical management including UM/CM, Grievance and Appeals, inpatient and outpatient services, medical policy, Benefit configuration, clinical claims review, and delegated vendor oversight.
  • In-depth experience of NYS Medicaid and CMS requirements
  • Knowledge of and experience managing care information systems
  • Advanced degree and/or health care management (MBA, MPH, MHS, or MHA) strongly preferred

Licensure and/or Certification Required

  • Requires a valid, unrestricted New York State Registered Nurse (R.N.) license

Professional Competencies

  • Integrity and Trust
  • Customer Focus
  • High level of proficiency in the use of Microsoft Word, Excel, and PowerPoint
  • Written/Oral Communication
  • Ability to lead and manage significant change
  • Strong leadership skills are a prerequisite, including excellent interpersonal, communications, problem solving and negotiating skills
  • Ability to work cross-functionally and collaboratively across the leadership team
  • Ability to think strategically and act tactically
  • Ability to thrive in a fast-paced environment, flexible to ongoing change
  • Confident, autonomous, solution-driven, motivating, holds high standards of excellence, diplomatic, resourceful, intuitive, dedicated, resilient, and proactive
  • Upbeat, positive, outgoing, and a doer
  • Strong urgency toward task accomplishment
  • Ability to form effective working relationships with a wide range of individuals

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