TITLE: Director, Utilization Management
DEPARTMENT: Health Services
REPORTS TO: Vice President, Health Services
FLSA: Exempt

Position Summary: The Director, UM is responsible for the day-to-day management and operations of the Utilization Management Team within the Health Services Department. The Director works in conjunction with the UM Nurse Supervisor, and UM Supervisor ensuring that care is coordinated while utilizing sound medical judgment within the member’s benefit plans. The Director is responsible for trending reports, identifying areas of concern and suggesting alternatives. The Director works collaboratively with the members, providers, health plans, and other NAMM departments to maximize members’ benefits within a cost effective environment.

Essential Roles and Responsibilities:
I. Staff Development and Mentoring
  • Interviews, trains and evaluates output and performance of the Utilization Management staff.
  • Plans and oversees ongoing education of personnel regarding departmental policies, procedures (i.e., monthly staff meetings, etc.).
  • Act as professional resource and provides suggestions for improvement in processes and time management.
II. Leadership
  • Develops and updates department policies and procedures with regard to Referral Management, Inpatient Utilization Review, and Complex Case Management.
  • Develops and Implements a comprehensive Utilization Management Program meeting the requirements of health plans, clients, and regulatory bodies.
  • Participates in developing department goals that reflect the vision of the company.
III. Customer Service and Client Relations
  • Works with other departments in a cooperative goal directed manner to achieve company goals (Claims, Provider Relations, Member Services, and Administration).
  • Collaborates with Medical Leadership to identify alternatives to contracted care when appropriate for members.
  • Attends internal and external meetings as necessary and/or required.
  • Provides input on system issues and enhancements.
  • Maintains a positive attitude and works closely with the referral staff and all other employees of the department to promote a synergistic environment.
  • Reviews / investigates difficult and/or exceptional preauthorization cases providing feedback to member, provider, Health Plan.
  • Assists in the preparation and presentation of reports to the UM Committees, as applicable.
  • Participates in the preparation of annual audits.
IV. Other duties as assigned
  • Fiscally responsible for maintaining operations within department budget.
  • Provides required reports as indicated and participates in special projects as needed.
  • Performs other duties as requested by the Vice President of Health Services.
Core Competencies:
  • Accountability: Takes responsibility for assigned work, following through to ensure goals are met or exceeded. Takes responsibility for decisions and/or actions in the job.
  • Leadership: Shows ability to take action to “get things done.” Sets achievable department and individual goals. Leads by example. Performs as a role model in meeting departmental standards. Able to influence the performance of others. Captures excitement and enthusiasm around a shared vision and department/company mission.
  • Coaching and Development: Provides regular performance feedback. Recognizes contributions. Motivates for increased results. Develops subordinates skills and encourages growth.
  • Communication: Maintains professional and positive interaction with physicians, offices, members and health plan staff. Presents information in a clear and concise format, ensuring mutual understanding through discussion, questions and feedback.
  • Cost-Effectiveness: Works within an approved budget. Conserves organizational resources. Develops and implements cost-savings measures. Contributes to the company’s profit and revenue.
  • Customer Service: Exceeds internal and external customer expectations by demonstrating understanding of customer/member needs to ensure effective delivery of a solution, product, or service that best fits their needs.
  • Planning and Implementation: Manages project team activities. Establishes tasks, priorities and stays on schedules. Involves appropriate resources in the planning forces and anticipates future needs. Schedules people, tasks, and delegates tasks appropriately.
  • Productivity: Effectively and efficiently uses time and resources to achieve work-related goals, organizing activities according to priority and the need for coordination and cooperation with others.
  • Problem Resolution/Decision-Making: Applies considered judgment to make decisions within assigned job duties, based on critical analysis and evaluation of the situation, the options, and their implications to elicit a positive outcome. Promotes dialogue to seek resolution of conflicts or problems with others. Seeks and offers solutions to problems.
  • Strategic Planning: Effectively formulates broad strategies, tactics and action plans. Plans, implements and monitors achievement of strategic objectives. Anticipates future consequences and trends accurately. Identifies opportunities to move the company toward the vision.
  • Responsiveness to Change: Demonstrates an openness to new ideas and ways of working; adapts to changing needs and situations; approaches issues with an openness to change and a willingness to pursue different approaches to achieve a positive outcome.
  • Teamwork: Works cooperatively and collaboratively with others, contributes to the “team” in its broadest sense; encourages participation, commitment, and an active contribution from him/herself and others in the pursuit of common goals. Actively seeks ways to apply knowledge and skills to help others.
  • Technical: Strong clinical knowledge, Health Plan benefits and requirements, State regulations regarding healthcare, CPT and ICD-9 coding, current contract requirements.
Minimum Qualifications
  • Registered nurse with current license in the state of practice.
  • B.S. in Nursing or other health related area preferred.
  • Minimum 4 years experience in utilization management, or other cost management programs required, preferably in managed care.
  • Three years experience in hospital-based nursing
  • Supervisory experience.
  • Must be a team player, have strong customer-service skills, problem solving skills, computer and analytical skills, and ability to multi-task in a fast-paced environment.