Job Description
Job Summary:
The Director, Utilization Management leads and manages all functions within medical management and level one case management programs to ensure consistent, efficient delivery of services throughout the healthcare continuum and demonstration of positive outcomes.
Essential Functions:
Leadership role in transitioning to the "next generation" of Care Management
Continuous review of business workflows to improve productivity and ensure member and provider satisfaction
Facilitate and promote problem identification, analysis and resolution
Expand ability to meet State contract requirements for existing and new populations with proactive processes to ensure success
Ensure monitoring of regulatory requirements and oversight of all submissions
Determine benchmarks, goals and outcomes for all programs as well as high cost, volume and risk conditions
Determine benchmarks, goals and outcomes for staff and implement an accountability system
Monitor CQI activities in accordance with regulatory requirements and URAC standards
Develop and coach employees
Build succession plan for Director and Manager positions
Foster relationships with hospitals, physicians and community agencies
Identify "wellness continuum" opportunities and develop successful blending of case, disease and medical management functions
Identify and report risk management issues for the department and CareSource as a whole
Perform any other job duties as requested
Education and Experience:
Bachelor's degree in nursing or related field required or equivalent years of relevant experience required
Master's degree preferred
Minimum of five (5) years of experience in one of the following: case management, medical management, disease management, quality improvement in a MCO required; quality improvement background preferred
Minimum of five (5) years management experience required
Experience in Disease Management preferred
Competencies, Knowledge and Skills:
Proficiency in Microsoft Office products including Word, Excel and PowerPoint
Internet research skills preferred
Leadership experience and skills
Change agent
Decision making/problem solving skills
Clinical data analysis and trending skills
Critical and systems thinker
Knowledge of trends in healthcare, managed care, Medicaid, case management, medical management and quality improvement
Excellent communication skills, both verbal and written
Management skills including human capital and project management
Ability to work independently and within a team environment
Attention to detail
Understanding of predictive modeling process/tools
Training/teaching skills
Strategic management skills
Negotiation skills/experience
Politically astute
Program grammar usage, phone etiquette and technical writing skills
Time management skills
Customer service oriented
Licensure and Certification:
Current, unrestricted license as a Registered Nurse (RN), Licensed Social Worker (LSW), Psychologist, or Professional Clinical Counselor (PCC) is required
Managed Care, Utilization management Case Management and/or Quality Improvement certification preferred
Working Conditions:
General office environment; may be required to sit or stand for long periods of time
Compensation Range:
$132,900.00 - $232,700.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type:
Salary
Competencies:
- Create an Inclusive Environment
- Cultivate Partnerships
- Develop Self and Others
- Drive Execution
- Influence Others
- Pursue Personal Excellence
- Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.
#LI-SW2
CareSource is an equal opportunity employer and gives consideration for employment to qualified applicants without regard to race, color, religion, sex, age, national origin, disability, sexual orientation, gender identity, genetic information, protected veteran status or any other characteristic protected by applicable federal, state or local law.
