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Director, Utilization Management(Experienced managed care leader with demonstrated success in oversight and accountability of UM performance and compliance. RN BSN or MSN preferred. PST preferred)

Director, Utilization Management(Experienced managed care leader with demonstrated success in oversight and accountability of UM performance and compliance. RN BSN or MSN preferred. PST preferred)

CareSourceDayton, OH, United States
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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.

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    Director Managed Care • Dayton, OH, United States