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GENERAL DESCRIPTION OF POSITION

The Director of Utilization Management (UM) is responsible for the clinical and operational management of the Utilization Management Department activities including utilization management, concurrent review, prior authorization, care coordination, discharge planning, retrospective review, and claims support, including staff management to ensure that all administrative utilization management (UM) processes are performed in accordance with applicable state and federal regulatory requirements, SCFHP policies and procedures and business requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily.

Manage and perform utilization management activates to ensure regulations, compliance, criteria, standards, and metrics as established by the Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), and Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and Healthcare Effectiveness Data and Information set (HEDIS) for Medi-Cal and Medicare lines of business.

Responsible for the development, design, implementation, and evaluation of the strategic plan for the UM department including the UM program, work plan, evaluation, and oversight of delegated UM functions.

Maintain accountability for utilization management functions to achieve business and clinical outcomes, meeting contract requirements, and supporting cross departmental initiatives with providers and members.

Manage effectiveness of UM coordinators and nurse’s review, coordination, and processing of prior authorization, concurrent review, discharge planning, and transitions of care activities including appeals, claims, provider disputes in accordance with established policy and standardized guidelines.

Monitor and evaluation of under-/over utilization medical services and durable medical equipment for health outcomes analysis including but not limited to identifying gaps in care, cost effectiveness, vendor administration, and quality improvement opportunities through claims, encounter data, and prior authorization data.

Produce and submit regular reports and data analytics as required for, but not limited to, all medical services, compliance dashboard, regulatory requirements, productivity, clinical operations, benefit changes, implementation, and service quality monitoring.

SUPERVISORY/MANAGEMENT RESPONSBILITIES

Carries out supervisory/management responsibilities in accordance with the organization’s policies, procedures, applicable regulations and laws. Responsibilities include:

Recruiting, interviewing, and hiring.

Developing a high performing department culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives.

REQUIREMENTS – Required (R) Desired (D)

Current unrestricted California Registered Nurse (RN) license or qualified health care professional. (R)

Bachelor’s Degree from an accredited four-year institution. (R)

Master’s Degree in Nursing or related field. (D)

Minimum five years of experience in Managed Care, Utilization Management, Quality Improvement, or equivalent. (R)

Minimum five years of experience in a supervisory capacity in a managed care setting. (R)

Comprehensive understanding of applicable standards and regulations pertaining to utilization management programs for DHCS, DHMC, NCQA, CMS and NCQA. (R)

Knowledge of medical cording practices. (R)

Knowledge of MCG guidelines, InterQual criteria, Medi-Cal Provider Manual, or CMS Guidelines. (R)

Current working knowledge of Medicare and Medi-Cal rules and regulations. (R)

Ability to consistently meet accuracy and timeline requirements to maintain regulatory requirements (R)

Familiarity with Health Maintenance Organization (HMO), Independent Practice Association (IPA), and medical group contracting concepts, principles and practices. (D)

Strong attention to detail and able to concentrate without distraction in a fast paced environment. Able to adapt to a rapidly changing environment and to keep supervisor informed of any delays which could disrupt delivery of health care services or the internal operations. (R)

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans.