Director, Utilization Management
HealthNow New York Inc. - Buffalo, NY

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Position Summary: Our Corporate UM Director will develop, implement and enhance utilization programs, overseeing the incorporation and coordination of regulatory requirements including DOH, CMS, NCQA, and DOI for all areas of Healthcare Services. S/he will expand auditing practices for regulatory purposes and for billing practices of providers, and develop and implement Medicare policies and criteria for inpatient and skilled nursing services. Additional responsibilities include coordination of inpatient and case management quality improvement programs, development and review of outcomes of quality incentives for par facilities, and oversight of monthly meetings related to appeal outcomes and areas of process improvement related to policies. Our director will assess and monitor all above practices through analytical data while constantly monitoring quality of care of our members and enhancing relationships with par providers.

Detailed responsibilities:
  • Develops, implements and oversees the annual Medical Management Program, which includes ongoing monitoring of activity to assure compliance with and effectiveness of the program
  • Conducts quarterly and year-end analysis of utilization data to identify areas of potential under/over utilization as well as other areas of potential opportunities for care management and process improvement
  • Oversees the development of new corporate medical policies and collaborates with all areas affected by changes
  • Evaluates contracts for inpatient criteria. Sets and implements program
  • Oversees SIU / RIU in audit process of billing practices
  • Takes an active leadership role in attaining new vendors and assessing outcomes of existing and new vendors
  • Spearheads initiatives that lead to cost reduction and utilize outcome analysis to affect practice patterns
  • Develops, recommends and manages the operational budget of the department, which includes preparation, monitoring and controlling of expenditures
  • Demonstrates a thorough understanding and applies the principals of the Medical Management Program, CMS, URAC, DOH, DOI, DOL and NCQA standards, corporate initiatives, utilization management, and unit goals, meeting all regulatory requirements
  • Serves as liaison with hospital utilization units to communicate/facilitate program requirements/changes, identify/educate on opportunities to improve utilization practices, and to identify opportunities to partner with facilities/providers to improve quality of member care
  • Disseminates ongoing product/program information, serving as a community resource for treatment options including drug therapy to benefit/apply new treatment alternatives for members
Required Skills Primary Skills/Knowledge:
  • Comprehensive knowledge of managed care concepts
  • Record of successful management experience demonstrated by at least 2 years incumbency as a manager of care or case management
  • Demonstrated ability to participate within regional medical community to provide positive relations, interacting with hospitals, physicians, other providers, employers, state and regional councils and regulators, and tertiary care centers, as appropriate
  • Excellent time management skills
  • Project management skills
  • Public presentation skills
  • Excellent organizational skills and attention to detail
  • Excellent verbal and written communication skills; persuasive communication style
  • Strategic thinking/planning skills
  • Ability to work effectively with minor supervision
  • Ability to work in a fast-paced, face-to-face customer service role with daily work processing deadlines and interruptions
  • High degree of business maturity and demonstrated confidentiality
  • Previous vendor relationship management experience preferred
  • Demonstrated customer service orientation
  • Demonstrated change management and change catalyst competencies
  • Demonstrated leadership skills (coaching, mentoring, staff development)
  • Demonstrated personal accountability
  • Valid drivers license and acceptable driving history required due to travel involved with this position (DMV check will be conducted to review candidate's driving record)
  • Intermediate proficiency in MS Word, MS Excel, MS Powerpoint, MS Access, Visio, Lotus Notes and Internet
Required Experience Bachelors Degree (Nursing)

Current NYS Registered Nursing License and at least seven years broad spectrum healthcare clinical experience with 3+ years in a hospital setting. Previous experience in health care insurance or medical management and knowledge and understanding of benefit structure preferred.

Working Conditions:
  • Must be able to accommodate regional/national travel (auto or air)
  • Must be able to work in an office environment
  • Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks
  • Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc)
Required Licenses/Certifications:
  • Registered Nurse
  • Driver's License/DMV Check Required