Director, Utilization Management

• 100% employer health plan for employees and their eligible dependents
• Unique benefit offerings that are partially or 100% employer paid
• Rich and varied retirement plans and the ability to participate in multiple plans.
• Generous paid time off plans

• Lead and manage a team of utilization review professionals providing guidance, training, and performance evaluations.
• Monitor and evaluate the utilization of healthcare services, including appropriateness, efficiency, and medical necessity of treatments and procedures.
• Analyze data and generate reports on utilization trends, outcomes and quality indicators to support decision-making and process improvement initiatives. Reports to appropriate committees.
• Manage quality of performance criteria, policies and procedures, and service standards for the utilization management operations. Evaluate utilization reviews and determine program improvements.
• Develop and implement utilization review policies and procedures in accordance with industry standards and regulatory requirements.
• Direct and coordinate data gathering and record keeping legally required by Federal and State agencies, the Joint Commission, and hospital policies; participates in the risk mitigation, process of implementing new or revised processes, and projects
• Foster effective communication and collaboration with internal departments, external agencies, and insurance providers to facilitate the utilization review process.
• Participate in interdisciplinary committees and meetings to contribute to the development and implementation of quality improvement initiatives.
• Oversees the secondary review process; actively appeals denied cases when necessary and assists physicians with appeals. Maintains minimal denial rates by Medicare, MediCal, private and contracted payers through appropriate direction of utilization practices; assists physicians and hospital personnel in understanding UM matters.
• Perform all other duties as assigned.
• Prepares cost analysis reports and other data needed for the preparation of the departmental budget.
• Provides in-house educational programs as needed for both staff and physicians.
• Responsible for the recruitment, orientation, evaluation, counseling and disciplinary action of UM and administrative staff.
• Serves as a content expert to staff and internal departments and external partners; networks with other hospitals, nursing organizations, and professional organizations to keep abreast of changes within the profession.