Reporting to the Director of Care & Disease Management, this individual is responsible for the overall direction and management of utilization and training activities within the department. This includes budget management, long range forecasting, management of staff, determination of training needs and implementation of a management model that adheres to and meets corporate goals and objectives. This individual will work with internal and external clients to develop and implement innovative utilization and trend management programs. Key activities and responsibilities include developing strategies, operational targets and metrics related to utilization management initiatives that support and are in alignment with the corporate strategy. This individual may assume delegated responsibilities regarding the DM Care Management teams based on organizational needs.
Manage and advance a practice model that effectively and efficiently supports the strategic, clinical and financial goals of the company.
Implement and maintain data gathering strategies and reports that will quantify designated department activities and work flows.
Develop and maintain departmental budgets that reflect fiscal responsibility.
Lead, manage, coach, and develop staff to meet departmental goals.
Ensure the fair and equitable administration of personnel policies.
Develop and implement departmental policies.
Monitor the appropriateness of delegated utilization management entities.
Develop and monitor utilization management training activities for staff.
Lead and participate in company and affiliated agency committees and projects.
Ensure departmental compliance with all regulatory and accreditation agency standards.
Oversee the design, implementation, and operational execution of evidence-based utilization and care management activities.
Remain current with developing utilization and care management theories, promote continuous quality improvement in managing effective, efficient operations.
Interact with all levels of management to ensure that utilization management programs meet provider and patient care needs, and are consistent with provider contracts.
Identify systems needs to advance the collaboration with external constituents such as members, medical home providers and ACO, as well as internally to improve efficiencies within HPHC.
Other duties and projects as assigned.
Represent Director when not available
Registered Nurse with a BSN and a MSN or MBA or equivalent master’s degree required.
Minimum ten (10) years of related clinical nursing experience with 7 years of progressively responsible management experience in a health service organization with a utilization and care management focus.
In depth knowledge of utilization and / or medical policy criteria and processes.
MA. RN Licensure required.
Excellent communication, negotiation, presentation, organizational, analytical and problem-solving skills required.
Demonstrated computer skills (Word, Excel, Internet Explorer, Access, PowerPoint).
Strong leadership skills, including proven ability to motivate and manage staff.
Demonstrated ability to achieve established outcomes and objectives with diverse groups of customers, providers and stakeholders.
Ability to work cross-functionally, supporting multiple, simultaneous objectives.
Ability to build internal programs including detailed workflows, communication and metrics.
Foster teamwork as an attitude and a skill; willingness to be change agent.
Superb customer service focus; flexible and responsive to customer needs.
Car/driver’s license required.
Harvard Pilgrim Health Care - 6 months ago
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