Utilization Review Care Management Director

• Provide leadership and administrative oversight for coordination of patient services across multidisciplinary teams and the continuum of care
• Collaborate with Medical Staff, Nursing, Clinical Services, and Revenue Cycle leadership to promote high-quality care, financial objectives, and leadership development
• Oversee complex care management, social work, transition planning, behavioral health, and care coordination services
• Design, implement, and manage longitudinal care strategies for seamless transitions across care settings
• Lead initiatives and partnerships to optimize health outcomes and cost-effectiveness
• Travel to locations across the enterprise as required
• Oversee strategic planning, day-to-day operations, standards of care, and fiscally responsible care delivery
• Manage budgets, cost centers, and ongoing fiscal performance monitoring
• Lead workforce planning, recruitment, retention, staffing, development, and succession planning
• Oversee interviewing, hiring, onboarding, training, performance management, corrective action, and termination
• Facilitate coordinated clinical and non-clinical care with interdisciplinary teams and providers
• Partner with physicians to achieve clinical, operational, financial, and service excellence
• Ensure patient satisfaction and service quality goals are supported
• Build community relationships and integrate community resources
• Ensure compliance with regulatory requirements for discharge planning, conditions of participation, and care management

• Current Registered Nurse (RN) license or Licensed Clinical Social Worker (LCSW) license in state of practice
• Bachelor of Science in Nursing (BSN) OR Master of Social Work (MSW) from an accredited institution; degree verification required
• Care Management Certification within 24 months of hire or promotion
• Demonstrated management experience in Care Management or related area
• Demonstrated experience in hospital or ambulatory case management, social work, or related areas requiring knowledge of the current healthcare environment, healthcare regulatory matters, and healthcare reimbursement
• Demonstrated knowledge and oversight of government regulations, contractual requirements, and NCQA accreditation standards
• If an RN, Master of Science in Nursing (MSN) from an accredited institution must be obtained within four (4) years of hire or promotion (preferred qualification)
• Professional experience working in an integrated delivery system that includes a health plan (preferred)
• Experience directing other clinical areas, collaborating with physicians, developing clinical strategies, implementing operational efforts, and measuring outcomes (preferred)
• Experience evaluating technology solutions to support care management functions (preferred)
• Experience developing collaborative relationships with payors to address healthcare needs across the continuum (preferred)
• Experience requiring strategic thinking and planning skills and developing proposals, pilots, and projects from conception to implementation (preferred)
• Ability to meet stated physical requirements, including reading information, communicating verbally, hearing, manual dexterity, and frequent computer use
• For roles requiring driving, ability to drive a vehicle

Demonstrates expertise in care management, including oversight of multidisciplinary teams, strategic planning, and compliance with healthcare regulations. Proven ability to lead initiatives that enhance patient outcomes and optimize operational efficiency.

• Registered Nurse (RN) License
• Licensed Clinical Social Worker (LCSW) License
• Care Management Certification
• Management Experience in Care Management
• Knowledge of Healthcare Regulatory Matters

• Care Management
• Complex Care Management
• Behavioral Health Oversight
• Budget Management
• Performance Monitoring
• Strategic Planning
• Operational Excellence
• Clinical Strategy Development
• Healthcare Reimbursement Knowledge
• Regulatory Compliance

• Leadership
• Collaboration
• Communication
• Interpersonal Skills
• Problem-Solving

• Care Management Certification
• Bachelor of Science in Nursing (BSN)
• Master of Social Work (MSW)
• Master of Science in Nursing (MSN)

• Integrated Delivery System
• NCQA Accreditation Standards
• Healthcare Environment
• Community Resources
• Patient Satisfaction