Director of Utilization Management
at RCM Health Care Services

Date Posted: 5/29/2019

Job Description

Director of Utilization
The Director is responsible for the planning, organization, implementation and evaluation of all activities and personnel engaged in Utilization Management (UM) departmental operations. This position will provide leadership and direction to the Utilization Management department to ensure compliance with all local, state and federal regulations, that accreditation standards are current, and all policies and procedures meet current requirements.
  • Direct all aspects of clinical and administrative utilization management staff activities.
  • Oversight of utilization program, to include:
    • Developing and maintaining effective authorization review processes and evaluates and recommends improvements where indicated.
    • Ensures department policies, procedures and workflows support staff in daily activities and meet regulatory, contractual and accreditation standards. Assists the Medical Directors, UM workgroup, and subject to approval by the UM committee, in the development, evaluation and application of all utilization criteria used for clinical decision making.
    • Collaborates with the UM Medical Director and UM workgroup, and subject to approval by the UM committee, maintains the utilization management program description, prepare the yearly utilization management program evaluation and quarterly updates to the work plan.
    • Develops and implements business plans to evaluate existing programs or to be used as a basis to determine if new programs are to be implemented.
  • Leads the staff responsible for Utilization Management workgroups and the Utilization Management committee.
  • Coordinates utilization activities with Long Term Services and Support, Case Management, and Population Health Management to improve health outcomes, promote appropriate use of resources and align with organizational and/or departmental goals and objectives.
  • Monitors and tracks services provided from the health plan service area and/or out of network.
  • Tracks, analyzes and develops strategies to address outlier performance of utilization metrics and reports on administrative quality indicators pertaining to Utilization Management.
  • Maintains inter-agency relationships (CCS, County Mental Health, etc.).
  • Hires, trains, and coaches managerial and supervisory staff. This includes fostering of staff development, ownership, accountability, educational opportunities, team building, and career development.
  • Develops and directs departmental structure, lines of accountability, job descriptions, interview and hire new staff members, orientation, training programs for all new and existing staff and annual staff evaluation and satisfaction process.
  • Collaborates with all departments within Medical Affairs and the health plan on the development of special projects/programs as required.
  • Directs departmental annual budgetary process, to include preparation and approval of operating and capital budgets per policy. Monitor performance and initiate corrective action as necessary to prevent budget variance.
  • Responsible for on-call activities after hours to ensure coverage on weekends and or holidays and extended timeframes when regular staff are not on duty or available.
  • Maintains current knowledge of regulatory requirements pertinent to Utilization Management (DHCS, CMS, MRMIB, DMHC).
  • Responds to providers or internal staff who have concerns within departmental standards.
  • Other projects and duties as assigned.
Required Skills
  
  • Communicate effectively with health professionals and administrators, both verbally and in writing.
  • Work in an extremely fast-paced environment with multiple competing priorities and matrix reporting relationships.
  • Make decisions in a timely manner and clearly communicate to all organizational levels at both a vertical and horizontal manner.
  • Present statistical and technical UM data in a clear and understandable manner utilizing appropriate visual aids.
  • Effectively supervise and coordinate the work of workgroups engaged in quality improvement activities.
  • Communicate findings of utilization reports to providers and internal or external stakeholders.
  • Present data and information to a wide range of groups using a variety of delivery methods.
 
Qualifications:
  • Current, unrestricted RN License to practice in the State of California is required.
  • Minimum 7 years of utilization management experience in a managed care environment, preferably with Medicare and Medicaid populations.
  • 5+ years of supervisory experience required.
  • California Medi-Cal and Medicare benefits, regulations and standards.
  • NCQA and CMS standards, Quality Improvement studies, HEDIS reporting.
  • Data collection and analysis, and management practices as related to quality of medical care.
  • Proficiency in the use of computers and main-frame or web-based systems as well as Windows-based PC applications with emphasis on word processing and spreadsheet software; Oracle, MS Word and Excel preferred.
  • Strong clinical skills.
 
 
 
 
 

Job Snapshot

  • Employee Type: Full-Time
  • Location: Orange, CA
  • Job Type: Management
  • Experience: At least 7 year(s)
  • Date Posted: 5/29/2019

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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