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Director of Utilization Management
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Job Description

The Director of Utilization Management is responsible for managing daily operations of UM and CCS to ensure performance meets contract standards and regulatory requirements with 100% quality control. The Director is also accountable for setting short and long-term goals, determining objectives, and managing referrals of service or cost effectiveness by working closely with other departments.

  1. Ensure UM operations meet policy and procedure performance metrics, quality assurance program standards and the requirements of laws and regulations.
  2. Conduct ongoing analysis/assessment of operational performance for continuous process improvements, improved efficiency, and improved customer satisfaction.
  3. Meet with staff regularly to discuss and provide training on new health plan/legislative requirements and processes, identify issues, barriers and process improvement to UM workflow.
  4. Work with Director of Clinical Services and Medical Director to ensure that all authorization requests are reviewed, processed and responded to and in accordance with the IPA’s policies and procedures for delegated UM activities.
  5. Follow up with authorizations that require additional patient information.
  6. Provide UM trend reports to the Director of Clinical Services, Medical Director and COO.
  7. Comply with health plan monthly/quarterly/annual reporting requirements and generate reports for review by Director of Clinical Operations prior to submission.
  8. Prepare and oversee health plan delegation audits for UM.
  9. Conduct UM committee meetings and participate in health plan JOCs.
  10. Monitor UM activity to report over/under utilization of services to the Utilization Committees.

Job Requirements

We are looking for a qualified RN with experience at the Supervisor, Manager or Director level; running the Utilization Management department. This position requires:

  1. an active RN license in the state of California
  2. At least 5 years supervisory experience in UM
  3. 5 years of Managed Care experience 
  4. a bachelor’s degree in a health related field 
  5. knowledgeable in local, state, and Federal rules and regulations
  6. strong ability to manage and lead a team 






 






Job Snapshot

Employment Type Full-Time
Job Type Health Care, Management
Education 4 Year Degree
Experience At least 5 year(s)
Manages Others Yes
Industry Healthcare - Health Services
Required Travel Not Specified
Job ID 16A*
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Director of Utilization Management


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