Director – UM PAC

The Director of Utilization Management for the Post- Acute Care (PAC) Program will provide leadership and oversight of clinical and utilization management (UM) activities for programs in accordance with company policies and procedures. Works with the CareCentrix operations management team to develop, implement and manage effective UM initiatives designed to position CareCentrix as an industry leader for excellent clinical outcomes by obtaining optimal financial results for CareCentrix and their customers.

Supports and oversees Utilization Management activities to assure positive outcomes and that expectations are exceeded. Assures that UM activities are compliant with regulatory and accreditation agency standards and client specific requirements. Collaborates with Medical Directors, Product, Account Management, Clinical Management, Client Services and Health Plans in the development of clinical and UM program initiatives. Works with CCX senior leadership Clinical Management to develop, direct and implement best practices for utilization and authorization management. Sets priorities and goals ensuring utilization performance, compliance and quality standards are met.

Assists with the development of reporting strategies and implements plans to ensure all outcomes are within stated objectives. Ensures appropriate staff training for all new clinical initiatives and monitors outcomes/performance. Directs and implements performance improvement activities to achieve desired goals when necessary. Ensures that information is documented/identified enabling the collection and root cause analysis of data to identify opportunities for improvement related to clinical programs. Participates in educating associates, management, customers, payers and physicians in best practices and protocols of care that drive excellent clinical performance and exceptional quality outcomes as well as optimizing financial results. Is the primary point of contact and responsible individual in internal and external audits of UM activities and outcomes.

In this Job, you will:

• Possess excellent communication (verbal/written), organizational and interpersonal skills
• Manage multiple tasks, be detail oriented, be responsive, and demonstrate independent thought and critical thinking
• Support and oversees Utilization Management activities to assure positive outcomes and that expectations are exceeded
• Assure that UM activities are compliant with regulatory and accreditation agency standards and client specific requirements
• Collaborate with Medical Directors, Product, Customer Service Center (CSC), Account Management, Clinical Management, Client Services and Health Plans in the development of clinical and UM program initiatives
• Work with CCX senior leadership Clinical Management to develop, direct and implement best practices for utilization and authorization management
• Set priorities and goals ensuring utilization performance, compliance and quality standards are met
• Assist with the development of reporting strategies and implements plans to ensure all outcomes are within stated objectives
• Ensure appropriate staff training for all new clinical initiatives and monitors outcomes/performance
• Collaborate with account management, client services and network management to provide education and training to referral sources and providers
• Direct and implements performance improvement activities to achieve desired goals when necessary
• Ensure that information is documented/identified enabling the collection and root cause analysis of data to identify opportunities for improvement related to clinical programs
• Participate in educating associates, management, customers, payers and physicians in best practices and protocols of care that drive both excellent clinical performance as well as optimizing financial results
• Be the primary point of contact and responsible individual in internal and external audits of UM activities and outcomes
• Participate in client meetings (JOCs) and provider/market meetings as the senior UM leader
• Participate in the UM management team as a leader in the organization
• Encourage and fosters an environment of teamwork, communication, collaboration and readiness for change
• Set an example for excellence, professionalism, accountability, innovation, compassion, integrity, and honesty
• Interview, selects, manages and develops new and existing associates to develop a high-performing team with opportunities for growth in the organization. Participates and is timely and compliant with the performance review and management process
• Conduct regular team meetings and meetings with direct reports
• Administer CareCentrix employee terminations, ensures appropriate paperwork is processed, conducts exit interviews, and monitors/tracks reasons for termination
• Participate in special projects and performs other duties to make the operation successful

You should get in touch if: (experience & education)

• Bachelor or Master’s degree in Healthcare field preferred Active RN licensure required with a minimum of 8 years of clinical experience
• Licensed professionals are required to possess a current license from their home state without restrictions
• Wide-ranging knowledge and experience with utilization management and accrediting agency standards
• Inclusive of industry standard guidelines such as Interqual, MCG and CMS
• Advanced education highly desired with additional training in the applicable clinical field
• Experience with program development desired
• Experience with data analysis and the design and use of clinical measurement systems
• Excellent verbal/written communication and presentation skills also required

What we offer:

• Full range of benefits including Health, Dental and Vision with HSA Employer Contributions and Dependent Care FSA Employer Match
• Generous PTO, 401K Savings Plan, Paid Parental Leave, free on-demand Virtual Fitness Training and more
• Advancement Opportunities, professional skills training, and tuition /exam reimbursement
• PayActiv - access earned income in between pay checks
• Walgreens Discount - receive up to 25% off eligible items
• Great culture with a sense of community

CareCentrix maintains a drug-free workplace

#IDCC

We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law.

CareCentrix accepts applications on an ongoing basis until a candidate is identified.