naviHealth is changing the face of healthcare. We are an innovative market leader in Post-Acute Care. We have a passion for excellence and making a difference in the lives of the elderly population as well as their loved ones. Our shared mission and energy makes us unique. Come be an integral part of naviHealth’s continued success.
The Director of Utilization Management will report to the SVP of Health Services and provide leadership to the clinical Utilization Management Managers executing on the delegated functions for Medicare Advantage, commercial and Medicaid Post-Acute Care partners. This dynamic position will be responsible for cultivating a strong leadership team that will provide daily direction and oversight of delegated functions. As part of the Health Services Leadership team, this role will create strong working relationships with the Senior Clinical Managers and General Managers in the field to truly understand their customer needs and challenges and to participate in appropriate needs analyses, establishing KPIs and tracking/trending key UM metrics to facilitate collaborative solutions. This key position will be responsible for oversight of key metrics and utilization patterns to identify trends across the continuum of Post-Acute care. This role will serve as a subject matter expert in the areas of SNF, IRF, LTAC and Home Health utilization management including CMS/NCQA policies and procedures, day to day operational regulatory processes, and being a point person for day to day questions. This role will be the lead for fostering new Utilization Management Managers and ensure that all UM Managers understand operational reports, metrics and can identify trends and areas of opportunity within their teams and health plan partners. Through an ongoing oversight and management process of key process indicators, this role will seek opportunities to continually improve the effectiveness and efficiency of the department. The Director of Utilization Management will foster efficacious relationships with health care providers to promote continuity and coordination of care while establishing effective methods to enable the management of risk.
Accountabilities in this role
Provide leadership to his/her leadership team focusing on achievement of enterprise objectives and contractual delivery commitments specific to the delegated activities (including but not limited to: Utilization Management functions, utilization trends, QIO appeals processes and tracking, and provider appeals).
Manage to meaningful and relevant operating metrics and key performance indicators to facilitate ongoing evaluation in meeting established goals and objectives for the utilization management process, outcomes and member/provider satisfaction.
Review analysis of relevant UM program data no less than monthly, provide recommendations for action to appropriate committee/leadership, and implement approved actions (including but not limited to: turnaround times – standard and expedited, QIO metrics, denial rates by level of care, staffing ratios, Quality Excellence Audit results).
Facilitate annual UM documents (program, work plan, policies/procedures - including medical necessity criteria, and prior year’s evaluation, including measurement of overall UM program effectiveness, using established goals, metric results, and associated benchmarks) and facilitate the adoption of these by appropriate committees.
Participate in high-level customer meetings when required to represent the Health Services leadership and report on strategic initiatives to improve operations, quality and provider satisfaction
Recruit, retain and develop a strong team of leaders to provide ongoing leadership to their colleagues, ensure they understand how to pull and analyze UM metrics, and follow all defined Human Capital processes
Participate in the Quality Oversight Committee processes and subcommittees as assigned
Work with functional leadership to establish and convene appropriate governance committee(s) for the UM programs.
Develop and adhere to department budget including growth planning.
Support new client pre-delegation and implementation activities
Execute on delegation audit commitments per contracts and CMS/NCQA expectations
Implement management processes according to organization and department policies and procedures.
Work collaboratively with key staff to identify opportunities for improvement, conduct appropriate trend analysis, and develop/implement action plans to address identified opportunities.
Participate in physician, hospital, and ancillary provider education.
Foster excellent working relationships with all stakeholders. Ensure compliance to all applicable regulatory and accreditation standards.
Bachelor’s degree in a healthcare-related field.
Active Registered Nurse (RN) or Physical Therapy (PT) license.
Master’s Degree in business or healthcare-related field preferred
Minimum of 10 years managed care/health plan UM experience.
Minimum of 7 years leadership/management experience with demonstrated interaction with senior leaders.
Minimum of 5 years of direct clinical experience.
Minimum of 3 years of demonstrated leadership of other leaders
Strong knowledge of health plan accreditation, CMS/NCQA regulatory standards, and regulatory reviews.
Significant experience in operational planning/execution within a managed care organization strongly preferred
Process Improvement Training or Six Sigma Certification preferred
Accreditation/certification of UM programs preferred.
Familiarity with InterQual
Cardinal Health is an Equal Opportunity/Affirmative Action employer.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex,
sexual orientation, gender identity, national origin, disability, or protected veteran status.
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The service that Cardinal Health delivers sets it apart from other companies. Cardinal Health is a one-stop shop. We provide great service and great products, at a great price. The most satisfying aspect of my work is that it is purpose driven.
At the end of the day, I know that what I have done has impacted someone’s life.
Rebecca, Medical Coordinator – Midwest and Southeast Regions