Director, Utilization Management Operations

Job Summary:

The Director, Utilization Management Operations assists the UM Department with all open projects and progress towards company and department initiatives including program descriptions, evaluations, policies, procedures, new business requirements, contract compliance and execution, and all related activities

Essential Functions:

Manages and prioritizes UM and related projects, and ensures timeliness and adherence to completion

Responsible for gathering and prioritization of business requirements for departmental requests including regulatory reporting

Monitors performance across programs to identify improvement opportunities, leverage best practice and knowledge sharing for the purpose of improving outcomes through the standardization of evidence-based practices

• Leads collaboration with all clinical teams and other stakeholders to ensure coordination and communication
• Assists with the monitoring of legislative/governmental activities with the goal of coordinating the full integration of clinical services, identifying opportunities and issues
• Supports the ongoing, data-driven approach to improve outcomes and experiences for members
• Supports and leads readiness activities for implementation of new business and programs
• Develops program documents and operational workflows
• Engages stakeholders to ensure alignment across the organization
• Adds services and processes related to the development of new lines of business as required
• Recruits, develops, and leads key staff
• Perform any other job-related instructions, as requested

Education and Experience:

• Bachelor’s Degree or equivalent years of relevant work experience is required
• Master’s degree in Health Care Administration and two years of post-degree professional experience is preferred
• Minimum of five (5) years medical management operations, leadership, program, or management experience is required
• Minimum of one (1) year Utilization Management experience preferred
• Experience implementing programs with focus on integration is preferred
• Experience with Medicaid, Medicare, Commercial and Managed Care is preferred

Competencies, Knowledge and Skills:

• Strong Knowledge of Visio, Microsoft Word, Excel, PowerPoint and Project
• Strong communication Skills; written and verbal
• Ability to work independently and within a team environment
• Strong organizational, time management, analysis, and problem solving skills
• Ability to manage a project from start to finish