Utilization Management Director - Inpatient; Hybrid

PURPOSE

Director Utilization Management (Inpatient) provides strategic leadership of the inpatient utilization management team and is responsible for the design, assessment, implementation and outcomes of inpatient utilization management strategies using a multidisciplinary approach to enhance member engagement, improve access to quality care and the use of cost‑effective health resources. Establishes performance metrics to ensure the needs and requirements of our members, providers, and regulators are met in accordance with accreditation standards, CMS requirements and state, Federal and local laws, and in alignment with Care First's business strategy.

Plans, directs and evaluates the full scope of utilization management services offered in collaboration with the preservice UM Director, and works closely with leadership, members, providers, vendors, accounts, and other strategic business partners.

Plans, organizes, and manages inpatient utilization review programs. Directs the utilization of referral services. Prepares and monitors budgets for programs to report performance measurements. Enhances quality of care by assuring compliance with policies, including safety, infection control, regulatory and accreditation requirements, and quality assurance. Directs staff, assigns work, reviews and evaluates hiring methods to meet departmental needs. We are looking for an experienced clinical leader in the greater Baltimore/Washington metropolitan area who is willing and able to work in a hybrid model.

The incumbent will be expected to work a portion of their week from home and a portion of their week at a Care First location based on business needs and work activities/deliverables that week. The ideal candidate will have led inpatient utilization management function in payor organization with a working knowledge of Guiding Care or similar platform.

• Administers policies and procedures of inpatient services.
• Determines eligibility of programs ensuring compliance with board approved regulations. Monitors changes in regulations and proposes related changes in regulations and procedures.
• Oversees the negotiations of access to care in specified targeted areas. Maintains relationships with providers who provide services to patients and pursues a responsive system for authorization of services and approved claims.
• Oversees retrospective reviews, case appeals, billing coordination, and clinical support.
• Ensures that staff is fully trained and competent on standards of practice of Utilization Management, reimbursement methodologies and treatment coding.
• Directs the strategic and the day‑to‑day activities of the Department, including coaching and guiding individuals and teams in order to implement departmental, divisional, and organizational mission/goals. Recruits, retains and develops a high performing team. Evaluates performance of each team member, generates development plans and sets goals within the context of the corporate policies and procedures. Develops annual goals, and prepares, monitors, and analyzes variances of departmental budgets in order to control and appropriately allocate resources.
• Monitors utilization patterns, such as demographics of service, revenue, and expenditures by preparing statistical reports. Presents status of key performance indicators and makes recommendations on continuous improvement opportunities to the executive leadership team.

This position manages people.

Bachelor's Degree in Nursing OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

• Health Services RN – Registered Nurse – State Licensure and/or Compact State Licensure.

8 years’ Experience in a clinical and utilization review roles. 3 years’ Management experience.

• The ideal candidate will have led inpatient utilization management function in payor organization with a working knowledge of Guiding Care or similar platform.

• Proficient…