Director of Utilization Management
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- Excellent Pay and Generous Benefits including a Pension and Continuing Education Reimbursement
- Excellent Team Orientated Culture
- Free Gym for Employees
- "Best Place to work in Monterey County" 11 years in a row!
Position: Director of Utilization Management
Location: Monterey, CA
Reports to: Chief Medical Officer
Direct Reports: Aspire Health Services Intake & Clinical Review staff
Under the supervision of the Chief Medical Officer (CMO) of Aspire Health Plan, the Director of Utilization Management is responsible for operational oversight and performance of Intake, Prior Authorization, Utilization Review practices and Correspondence to ensure compliance with regulatory, contractual and accreditation requirements. This role is responsible for the planning and growth of the department to meet current and future needs of the organization.
The Director will work collaboratively with key stakeholders such as delegates carrying out care management functions, provider services, customer services, the pharmacy benefits manager, members, and providers. The success of this position requires the ability to foster communication and teamwork among physicians, medical management staff, corporate departments, vendors, and senior leadership.
- In conjunction with the CMO, develop budget for the UM function within the Health Care Services (HCS) department annually.
- Allocate and manage resources within the budget to accomplish HCS objectives.
- Develop, establish, and implement goals, objectives, and policies and procedures that guide and support the provision of UM services.
- Assist in establishing objectives and annual goals in conjunction with the CMO, QI committees, and Aspire department heads.
- Assist in the development of the QI annual work plan.
- Review rules, regulations, policies, procedures, guidelines from governing agencies, communicate requirements to HCS delegates and internal and external customers as indicated, and assure implementation of applicable HCS policies and procedures to address requirements.
- Using feedback from customers and work partners, forecasts future needs in relation to growth and / or new services and plans for growing the department capabilities over a significant period of time
- Maintain knowledge of healthcare industry trends related to utilization management, conformance to regulatory requirements, reporting of clinical performance data and targeted areas for health system improvement.
- Maintain professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
- Drives the implementation of processes and system enhancements which will improve the overall quality and service provided by the UM teams
- Establishes and maintains appropriate systems and scorecards for measuring necessary aspects of operational management and development
- Analyzes trends and implements departmental initiatives based upon data provided through the reporting of production, quality, financial and audit data
- Maintains a personal level of professionalism through attendance at required meetings and evaluating problematic issues using all resources for resolution. Oversees the recruiting, performance, development and mentoring of Prior Authorization, Correspondence, and Intake staff
- Encourages, initiates, and participates in cross functional / departmental discussions and initiatives to remove barriers and improve communications and work flows
- Collaborates with senior level business, medical and IT leaders on company-wide initiatives related to medical costs, revenue, payment integrity, encounter submissions / responses / reconciliation, payer partner strategy, and UM initiatives
- Motivates and guides management staff cascading healthy management practices and positive culture to employees. Key to effectiveness of the Director is the ability to motivate and coach management team members in their development as effective managers of people
- Maintain communication with the CMO, with routine updates on operation updates, issues, concerns and other pertinent information
- Assign goals to care coordination staff, monitor the work of direct reports, and evaluate performance.
- Provide training and coaching as needed to ensure staff is meeting performance standards.
- Act as a liaison, in conjunction with other Aspire departments, between members, their families, and providers to facilitate problem solving and patient care.
- Assist in the implementation of the QI annual work plan.
Program Oversight and Management
- Sets organizational priorities for the team and defines approach and effort for team direction
- Plans, develops and implements policy and procedure for current and future workflows within the related UM areas to meet agreed organizational performance plans and expansion within agreed budgets and timeframes (relevant areas of operation include those noted above)
- Manages departmental functions, workflows, policies and procedures to ensure that all Federal and State regulations and contractual agreements are followed. Ensures all regulatory requirements and training programs are disseminated and understood
- Oversees the management of staffing ratios of all UM personnel, the assignment of duties, the supervision of the effectiveness of the UM program related to staff, within the structure of the budget for the department
- Assist in researching, responding to, and resolving issues related to initial determinations and appeals.
- Manage HCS operations to optimize workflow, communication processes, and systems to manage patient care effectively.
- Assure HCS compliance with State and Federal requirements through regular monitoring and participation in periodic audits.
- Act as the Subject Matter Expert in delegation oversight activities including the performance of pre-delegation, ongoing monitoring and annual audits of HCS related administrative services.
- Monitor HCS activities, including but not limited to authorization processing times, quality assurance/ management reviews, utilization review reporting, and disease state management.
- Oversee delegated vendors carrying out quality and care management functions to ensure adherence to service level agreements.
Program Reporting and Evaluation
- Monitor, evaluate, and report on HCS activities, performance, and statistics for review and evaluation for internal use by management and applicable committees and for required public reporting.
- Trend and analyze quality, utilization and cost data, and assist in developing reports as indicated.
- Coordinate quarterly reporting of all HCS initiatives to all appropriate committees.
- Oversee HEDIS, Health Outcomes Survey, and CAHPS data analysis.
- Assist Compliance in development and oversight of HCS corrective action plans.
- Minimum 7 years in a leadership position in care management, preferably with some experience in health plan settings.
- Minimum 5 years experience supervising clinical staff.
- Experience working in a health plan or an integrated healthcare model.
- Experience with process development, program implementation and program evaluation desirable.
- Experience with Medicare Advantage and/or HMO and PPO programs desirable.
- Minimum Bachelor's Degree in health related field; Master's Degree in pertinent field preferred.
- Excellent written and verbal communication skills, facilitation, team building, strong organizational skills.
- Knowledge of State and CMS regulations.
- Proficient in the use of Microsoft Office applications; Excel, Word, Outlook, PowerPoint.
- Eligible to participate in local, State and Federal health care programs.
Aspire Health Plan is a locally owned Medicare Advantage HMO that provides comprehensive medical coverage to seniors and other Medicare recipients in Monterey County. We’re proud to be a community-centered organization backed by Montage Health, parent organization of Community Hospital of the Monterey Peninsula and Salinas Valley Memorial Healthcare System, parent organization of Salinas Valley Memorial Hospital. Over 700 doctors, many other healthcare providers, and all four Monterey County hospitals are part of the Aspire Health Plan network. It’s the care you need from people you know.
Aspire Health is an equal opportunity employer.