Director - Utilization Management

Location:

Avera Health Plans

Regular

Primarily days with possible weekends/evenings/holidays (United States of America)

Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

Accountable for oversight and execution of utilization review initiatives and strategies associated with utilization metrics. This position is responsible for providing leadership and strategic oversight for medical and domestic network utilization and clinical evidence-based guideline adherence, reviewing key performance, utilization, and quality metrics, and establishing and measuring employee performance and productivity metrics. This position will lead various projects and approach each in a critical, problem‑solving manner, while organizing, leading and developing teams to execute solutions.

This position is responsible for providing leadership of a well‑rounded team of nurses and healthcare staff, all aimed to facilitate the appropriate delivery of health care products and services in a cost‑effective, efficient manner to improve quality of care and health outcomes. The Director of Utilization Management will need to be knowledgeable in various aspects of all health plan lines of business, inclusive of commercial, marketplace, government, and self‑funded clients.

The position requires interaction with health system stakeholders, key leaders, vendors, delegated entities, healthcare providers, policy makers, and accreditation and government organizations.

• Work directly with the applicable leadership to provide operational oversight of clinical review services.
• Support ongoing review of utilization management processes to best align with organizational strategic initiatives.
• Monitors trends related to internal performance and vendor delegation.
• Develop key clinical, operational, and financial metrics for the health plan committees and leaders.
• Reviews key clinical and operation data to ensure the Health Plans' National Committee for Quality Assurance (NCQA) audit readiness and data integrity.
• Ensure integration of managed care principles into population health management initiatives.
• Develop utilization management quality programs to meet plan, CMS and accreditation body requirements.
• Complete regulatory submissions and ensure compliance with CMS, NCQA and internal Health Plan policies for all utilization management quality programs.
• Promotes financial stewardship through use of ethical business principles and applies to effective cost management, revenue generation, and risk mitigation.
• Designs systems of care that enhance the member experience.
• Responsibilities include interviewing, hiring, developing, training, and retaining employees; planning, assigning, and leading work; appraising performance; rewarding and coaching employees; addressing complaints and resolving problems.

The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

• Associate's in Nursing with advanced education and/or UM experience.
• 4-6 years Clinical nursing experience
• 4-6 years Experience in formal leadership.

• Bachelor's in Nursing.
• Master's in Business Administration, Healthcare Administration, Healthcare Management, or equivalent.
• 1-3 years Utilization management or managed care experience