Director-Utilization Management (Physical Health) (Full time, Remote)
Company: Alliance
Location: Morrisville
Posted on: January 24, 2023
Job Description:
The Director of Utilization Management (UM) for Physical Health
is responsible for administering and coordinating physical health
utilization management activities for Alliance. This position
ensures the UM Department operates as an integrated department
providing a holistic review of member's needs. The position is
responsible for overseeing a core component that ensures that
individuals receive the correct level and intensity of services
that results in positive outcomes. This job also develops systems
to monitor the appropriate utilization of both state and Medicaid
funds.
This position is full-time remote opportunity with the option to
work onsite.
Responsibilities & Duties
Develop and implement Unit goals and objectives
- Integrate the department and its functions into the
organization's primary mission.
- Ensure the Utilization Management Department serves as an
integrated department through effectively collaborating with the
Director of Behavioral Health Utilization Management and the Sr.
Director of Utilization Management
Manage and Develop Staff
- Work with Human Resources and the Sr. Director of UM to
maintain and retain a highly qualified and well-trained
workforce.
- Ensure staff are well trained in and comply with all
organization and department policies, procedures, and business
processes.
- Organize workflows and ensure staff understand their roles and
responsibilities.
- Ensure the department has the needed tools and resources to
achieve organizational goals and to support employees and ensure
compliance with licensure, regulatory, and accreditation
requirements.
- Actively establish and promote a positive, diverse, and
inclusive working environment that builds trust.
- Ensure all staff are treated with respect and dignity
- Ensure standards are transparent and applied consistently,
impartially, and ethically over time and across all staff
members.
- Work to resolve conflicts and disputes, ensuring that all
participants are given a voice.
- Set goals for performance and deadlines in line with
organization goals and vision.
- Effectively communicate feedback and provide ongoing coaching
and mentoring to staff and support a learning environment to
advance team skills and professional development.
- Cultivate and encourage efforts to expand cross-team
collaboration and partnership.
- Effectively utilize and teach to the team how to effectively
utilize authorization, claims and per diem data in order to remain
within Alliance's Cost of Care plan
- Supervise UM Physical Health employees to assure accountability
and productivity in meeting Department objectives and targets.
Oversee delegated UM vendors
- Oversee delegated vendors performing utilization reviews for
physical health services.
- Monitor UM vendors for compliance with delegation agreements
and corrective action plans.
- Report analysis of non-compliance when identified.
Oversee the UM Unit reviewing physical health services
- Ensure consistent application of medical necessity criteria for
physical health services.
- Participate in the development and implementation of department
policies and procedures
- Ensure compliance with performance measures outlined within NC
DHB, NC DMH contracts and all accrediting body standards.
- Protect client rights by ensuring all UM staff are trained and
follow due process procedures, including the timely processing of
treatment requests.
- Implement a system to maintain and assure that the
authorization of services provided by clinical care staff
appropriately address the service needs, types of service,
outcomes, and alternatives available to consumers.
- Refine and evaluate the methods of authorization for services
and treatment; develop strategies for accessing alternative to
care.
- Provide education to hospitals, nursing homes and other care
providers concerning departmental procedures and requirements for
approving length of stay extensions.
- Analyze and monitor community capacity for service needs,
service gaps, and the implementation of evidence based/best
practices.
- Advise on the Alliance Medicaid and Non-Medicaid benefit plans
that support the delivery and fidelity of evidence-based
practices.
- Implement and monitor systems to detect patterns of over and
under utilization and implements corrective plans.
- Advise the Utilization Management Committee regarding service
line trends and operational key performance measures.
- Perform other related duties as required by the immediate
supervisor or other designated Alliance Health administration
Inter-Departmental Collaboration
- Maintain accessible and close working relationships with all
applicable department heads and decision makers to develop a more
coordinated and streamlined service delivery system for individuals
and families throughout the service area.
- Identify opportunities for collaboration on inter-departmental
projects that reduces duplication and ineffeciencies across the
system.
- Work with the Medical Directors with decision making of medical
necessity cases, specialists, and primary care physicians
Knowledge, Skills, & Abilities
- Must be knowledgeable in Utilization Management managed care
principles and strategies
- Knowledge of physical health and co-morbid health
conditions
- Knowledge of diagnostic treatment guidelines/protocols, level
of care criteria
- Authorization/re-authorization Utilization Management
standards
- Ability to analyze data and develop corresponding
strategies
- Ability to develop and document workflows
- Written and oral communication skills
- Ability to analyze effectiveness of processes and make
adjustments to developed processes.
- Experience in acute clinical utilization review
- Experience in related duties in the delivery of patient care,
management of patient care providers, or project management in a
healthcare environment
- Demonstrates ability to interact with a wide variety of
individuals and handle complex and confidential sensitive
situations.
- Able to lead, delegate and problem solve
- Proficient in the use of computer and multiple software
programs.
- Ability to assist appeal efforts when medical care is denied by
various payor entities in a timely fashion.
Minimum Education & Experience
Bachelors in Nursing with seven (7) years' post-degree experience,
including at least two (2) years of supervisory experience and two
(2) years Utilization Management or substantially equivalent
experience;
OR
Master's degree in Nursing and five (5) years' experience including
at least two (2) years of supervisory experience and two (2) years
Utilization Management experience or substantially equivalent
experience.
Salary Range
$75,438.27to$129,865.03/Annually
Keywords: Alliance, Cary , Director-Utilization Management (Physical Health) (Full time, Remote), Executive , Morrisville, North Carolina
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