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UM Clinical Director - Southwest / Central Region
Beacon Health Options • US-Nationwide
Posted 5 days ago
About the Position:
We are currently seeking a dynamic UM Clinical Director to join our Utilization Management team! The Clinical Director is responsible for clinical oversight of utilization management activities for the organization. The primary focus of this position is on utilization management and the delivery of clinical care and service to health plan members. The Clinical Director of UM works in collaboration with the Assistant Vice President of Clinical Operations to ensure the UM needs of the organization are met.
- Develops, implements and monitors policies and procedures for UM precertification, concurrent review, post service review (retrospective chart review), clinical practice guidelines, clinical protocols, and reporting quality of care issues identified during the UM process.
- Monitors UM decision making through reviewing results of local office quarterly case audits and annual Inter-Rater Reliability testing
- In collaboration with the Assistant Vice President of Clinical Operations and the Clinical Director of CM develops and implements the UM plan in accordance with the mission, vision, values and strategic goals of the organization
- Oversees UM processes with regards to specialty programs to ensure compliance with Beacon’s policy guidelines, standard operation procedures, external regulatory requirements and URAC/NCQA accreditation standards.
- Utilizes established benchmarks to monitor, track, and trend aggregated, product specific and plan specific UM metrics. Utilizes this information in monthly meetings with clinical managers, who are accountable for the performance of their office/team
- Collaborates with the Assistant Vice President of Clinical Operations on census analysis and strategies to address
- Development of innovative practices based on evidence to improve UM efficiencies
- Ongoing review and revision of the UM module to improve clinical efficiencies
- Provides report and analysis to the Quality Improvement Council
- Provides direction to clinical managers in the reporting and analysis of plan specific UM metrics
- In collaboration with the Assistant Vice President of Clinical Operations adopts productivity standards, and sets benchmarks for all utilization review staff
- In collaboration with the Implementation team supports UM business development activities
- Represents Beacon at client meetings regarding UM trends
- In collaboration with the Vice President for Medical Affairs monitors changes in evidence based best practices and reviews level of care criteria on an at least an annual basis
- Responsible for compliance with all UM standards for both NCQA and URAC accreditations
- Collaborates with Director of Quality Management on all NCQA and URAC initiatives and readiness
- Has periodic consultation with practitioners in the field through attendance at professional meetings and conferences as well as through membership on various committees, i.e. Provider Advisory, etc. to which practitioners are invited.
- Education: Master’s degree or higher in a health related field preferred.
- Licensures: Current, valid, and unrestricted licensed behavioral health clinician and practice within the scope of their licensure. Re-verification will take place no less than every 3 years.
- Relevant Work Experience: 10 years of behavioral health managed care experience and 5 years of supervisory experience is required
Knowledge, Skills, & Abilities:
- Knowledge of current principles, procedures and knowledge of behavior health.
- Keen attention to detail and ability to multitask with ease
- Moderate skill level in MS Office environment (Outlook, Word, Excel, PowerPoint)
- Good written and verbal communication skills
- Desire to continually improve problem resolution skills
- Team player with an ability to work under pressure
- Ability to remain objective in all dealings with customers and maintain professional attitude at all times
- Ability to prioritize tasks and accomplish them in a timely fashion
- Excellent provider/customer relations skills
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Beacon Health Options is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled