Nationally recognized integrated health plan seeks a Director of Utilization Management to lead a CM/UM team in Southeastern Massachusetts. The Director of Utilization Management will: Manage criteria-based reviews of care, clinical appeals regarding medical necessity, and the interaction with claims payment policies and processes.
Support goals, contracts, and accreditation requirements of health plan by conducting reviews of clinical interactions and clinical documentation including reviews of case management, utilization management, vendor, and provider records.
Collaborate with local and national leaders including quality improvement, analytics, finance, network, ensuring a comprehensive approach to managing quality of care, service, and cost of care.
Provides expert input to finance regarding patterns of utilization and cost and high cost cases.
Manages a call center team and case management team

Requirements: RN, state of Massachusetts, BSN preferred
5+ years experience in case management/utilization management
3+ years UM leadership including mentoring and training staff
A background that includes strong clinical work, experience in managed care and managing a call center team
A depth of experience and strong understanding of managed care referral requirements
A strong familiarization with Medicare guidelines and authorization processes
Utilization management experience in an outpatient clinical environment.
Knowledge of ambulatory healthcare delivery and management.
Working knowledge of NCQA, and health plan requirements related to utilization management.
A strong understanding of ambulatory healthcare delivery and management
Demonstrated knowledge of prospective authorization process and workflow
A track record of accomplishment in handling multiple competing priorities
Working knowledge of Microsoft Office Suite, including Windows
High energy with demonstrated accomplishment in working independently and in a team environment
Experience overseeing contractual performance standards
Strong background in the reporting and analysis of managed care utilization data
Strong analytical skills
A track record of accomplishment managing UM/CM teams
Strong communications and leadership skills
Associated topics: analyst, cmo, demand generation, festival, fundraise, hospital, marketplace, principle gift, public relations, university relationship

* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.

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