Director, Behavioral Health - Utilization Management; Director III

Director, Behavioral Health - Utilization Management (Director III)

Cal Optima

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

We are hoping you will join us as a Director, Behavioral Health - Utilization Management (Director III) and help shape the future of healthcare where you'll be an integral part of our BHI - BH Utilization Management team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders.

This position has been approved to be Full Telework.

Telework approved: you are required to work within the State of California only. If Partial Telework is needed, you will also come into the Main Office in Orange, CA, at least two (2) days per week.

The Director for Behavioral Health (BH) Utilization Management (UM) will be responsible for the oversight, planning, organization, implementation, and evaluation of all activities and personnel engaged in departmental operations. You will provide leadership and direction to ensure compliance with all local, state, and federal regulations, ensure accreditation standards are current, and all policies and procedures meet current requirements. You will oversee Cal Optima Health's BH UM program for Cal Optima Health Community Network, Cal Optima Health Direct and the delegated health networks.

You will serve as a liaison for various internal and external committees, work groups and operational meetings. Together, we are building a stronger, more equitable health system.

• 50% - Leadership Functions
  • Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
  • Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department.
  • Directs all aspects of clinical and administrative UM staff activities.
  • Leads the BH staff responsible for UM work groups and the UM committee.
  • Tracks, analyzes and develops strategies to address outlier performance of utilization metrics and reports on administrative quality indicators pertaining to UM.
  • Maintains inter‑agency relationships, including California Children’s Services (CCS), County Mental Health, etc.
  • Develops departmental structure and lines of accountability, creates and revises job descriptions, interviews and hires new staff members, oversees training programs for all new and existing staff, and manages annual staff evaluations and satisfaction processes.
  • Directs departmental annual budgetary process, including preparation and approval of operating and capital budgets per policy; monitors performance and initiates corrective action as necessary to prevent budget variance.
  • Oversees on‑call activities after hours to ensure coverage on weekends, holidays and extended time frames when regular staff are not on duty or available.
  • Maintains current knowledge of regulatory requirements pertinent to UM such as the Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS), Managed Risk Medical Insurance Board (MRMIB) and Department of Managed Health Care (DMHC).
  • Responds to providers or internal staff who have concerns within departmental standards.
• 45% - Program Oversight
  • Coordinates utilization activities with Long Term Services and Support, Case Management, and Equity and Community Health to improve health outcomes, promote appropriate use of resources and align with organizational and/or departmental goals and objectives.
  • Monitors and tracks services provided from the health plan service area and/or out of network.
  • Collaborates with all departments within…