Maintains accountability for medical management functions to achieve the business and clinical outcomes for the health plan, meeting contract requirements, National Committee of Quality Assurance (NCQA) accreditation standards, and supporting initiatives with providers and members to manage cost of care. Oversees utilization management and criteria-based reviews of care, clinical appeals regarding medical necessity, and the interaction with claims payment policies and processes. Also oversees the health plans 24/7 Nurse Line program and the clinical management of crisis calls. Depending on SBU/product supported, supports goals, contracts, and accreditation requirements of health plan in conducting reviews of clinical interactions and clinical documentation including reviews of case management, utilization management, vendor, and provider records. Collects data following established procedures and analyzes findings for purposes of continuous quality improvement and for internal and external reporting. Interacts with multiple stakeholders internally and externally. Conduct staff audits, process audits and pre-delegation and delegation activities. Reviews audit results with appropriate stakeholder and manages trainings in conjunction with the trainer for individual and/or for unit learning gaps.
- Directs, coordinates and evaluates efficiency and productivity of utilization management functions. Works closely with SBU and vendors to assure integration, oversight, and efficiency of utilization management and appeals processes and for delegated functions. In collaboration with the national clinical team, assures that all utilization management-related activities meet the standards required for the state contract and NCQA.
- Leads and organizes the ongoing evaluation of the utilization management program against quality and utilization benchmarks and targets. Identifies opportunities for improvement; organizes and manages cost of care initiatives. Collaborates with local and national leaders including Quality Improvement, Analytics, Finance, Network, and other areas to assure a comprehensive approach to managing quality of care, service, and cost of care. Provides expert input to Finance regarding patterns of utilization and cost and high cost cases.
- Assures staff selection, training, and evaluation to promote the development of a high quality team and effective transitions of care with the clinical care teams.
- Works closely with and provides input to national health plan clinical team on program design, policies, procedures, workflows, and correspondence.
- Collaborates with Network leaders to design and implement successful methods for working with hospitals, home health, and other services providers. Ensures integration and efficiency of Network strategy and vendor relationships with utilization management and claims processes. Works closely with network on the training and evaluation of providers as well in resolving provider related issues.
- Directs staff who assure quality, inter-rater reliability and standards are met in daily operations. Responsible for resolution and communication of utilization management issues and concerns and corrective action plan activities and reporting.
- Participates as a member of health plan Quality Insurance Committee and co-chair health plan Utilization Management Committee.
- Collects, analyzes and prepares record/documents information for projects related to assessing the efficiency, effectiveness and quality of the delivery of managed care services. Prepares monthly performance reports with audit results. Presents findings at provider, customer, UM and CM meetings as needed.
- Audits and reviews case manager, Health guide, UM staff, vendor, and provider documentation and telephone interactions against health services quality monitoring standards, regulations, accreditation standards and contract requirements. Reviews vendor and/or provider records against clinical and procedural established standards and contract requirements.
- Leads and conducts ongoing activities which monitor established quality of care standards in the participating provider network, vendors, UM staff, Health Guides, and for case managers.
- Assists in the planning and implementation of activities to improve delivery of services and quality of care including the development and coordination of in-service education programs for vendors, providers, UM staff, and case managers. Makes recommendations as to required training based upon audit results.
- Responsible for monitoring and validating internal audit results and/or corrective action plans.
- Other duties as assigned.
General Job Information
Director, Utilization Management
United States of America
United States of America (Exempt)
Recruiting Start Date
Date Requisition Created
Clinical, Management/Leadership, Quality, Utilization Management
Bachelors: Nursing (Required), Masters: Behavioral Health (Required)
License and Certifications - Required
RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt
License and Certifications - Preferred
Other Job Requirements
- 3+ years in utilization management operations.
- 5+ years in health care quality improvement.
- Licensure is required for this position, specifically a current license that meets State, Commonwealth or customer-specific requirements. One or more of the following current, active licenses are required: BCBA, LCMFT, LCSW, LMHP, LPC or RN.
- Must have experience overseeing contractual performance standards.
- Experience with reporting and analyzing managed care utilization data.
- Strong verbal and written communications skills.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.