Director of Utilization Management Compliance
at RCM Health Care Services

Date Posted: 3/25/2019

Job Description

Director of Utilization Management Compliance

Company Info:
  • Health plan with strong commitment to helping its members stay healthy
  • Position will be Mon-Fri, business hours
  • Strong six figure salary with excellent benefits

Job Description:
  • Responsible for developing, integrating, implementing and monitoring compliance with the Utilization Management Plan including policies and procedures across health plans, NCQA and other regulatory agencies.
  • Serves as a liaison between the medical group and the governing agencies in accordance with the Office of the Medical Director/Quality Management Sessions (OMD/QS).
  • Works as a cross-functional team member with Care Management, Quality Improvement, Risk Management, MCA and Contracting.
  • Consistently exhibits behavior and communication skills that demonstrate our commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
  • Provides support to the OMD/QS meetings by presenting quarterly on issues/topics related to Utilization Management (UM) including delegation, regulatory requirements, policies, recommendations regarding compliance and utilization/quality issues related to home health and/or durable medical equipment.
  • Serves as liaison to the health plans in disseminating information to the Regional Care Management, Quality Improvement and Risk Management departments as appropriate.
  • Acts as a central resource with regards to regulatory requirements from participating regulatory agencies as well as health plan clinical review criteria and HMO benefits.
  • Oversees and conducts regional-based training to educate Care Management staff on health plan regulatory procedures and processes.
  • Responds in writing to all health plan UM requests and determines how best to meet these requests.
  • Manages, coordinates and facilitates annual health plan audits of components within the HCP corporate and network organizations. Responds in writing to correct any deficiencies.
  • Assists and facilitates consistency and compliance of Care Management in accordance with health plan, CMS and NCQA requirements.
  • Assists and makes recommendations for any revisions to the UM plan to meet these requirements.
  • Assists the Regional Care Management departments in the development of the appeals/denials process. Facilitates consistent policies and procedures throughout the organization.
  • Coordinates the submission of the health plan UM quarterly reports in a timely manner.
  • Monitors referral turnaround time to meet health plan regulatory compliance.
  • Oversees the processing and submission of all denial letters company-wide and ensures that denial turnaround times meet health plan regulatory compliance.
  • Develops UM tools to maintain UM and monitor regulatory compliance.
  • Participates in the development and implementation of enhancements to the Referral management system.
  • Maintains the departmental SharePoint site by authorizing, posting and/or updating of documents under the care Management site.
  • Develops and/or updates the Care Management departmental policies and procedures.
  • Uses, protects, and discloses patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.

  • Current unrestricted CA RN or LVN - CMC or CCM desirable
  • 2+ years of experience performing care coordination, utilization review, and quality management
  • 3+ years managerial experience in a Health Plan, IPA, or Medical Group setting REQUIRED

Job Snapshot

About Us

RCM Health Care Services offers career defining opportunities to candidates from the leading employers in health care. Whether you’re looking for a new job or seeking to hire the best medical talent, RCM Health Care Services has the solution for you. Since 1975, we’ve established ourselves as a leader in the recruitment industry by connecting thousands of healthcare professionals with placements that support their needs. If you’re looking to make the next move in your career, let RCM be your guide, we’re with you every step of the way!

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