Director, Utilization Management

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor of Science in Nursing (BSN) from accredited nursing program.

EXPERIENCE:

1. Five (5) years of prior management experience in Utilization Management in a managed care setting.

2. Eight (8) years of experience working in Utilization Management.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Master of Science in Nursing (MSN).

EXPERIENCE:

1. Utilization Management for Medicare and/or Medicaid populations.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Leads utilization management team policies and procedures to ensure compliance with corporate, state, and National Committee for Quality Assurance (NCQA) standards.

2. Leads utilization management team on performance, improvement, and career growth path considerations.

3. Leads process improvements for the utilization management team to achieve cost-effective healthcare results and presents to senior leadership team.

4. Hires and manages an engaged workforce to deliver exceptional customer service and quality.

5. Sets team direction, resolves issues and provides mentoring and guidance to team.

6. Executes the overall strategy for onboarding, hiring, and training new utilization management team members to ensure adequate training and high quality-care to improve member and provider experience and ensure compliance.

7. Responsible for components of the department's budget while collaborating inter-departmentally with senior leadership.

8. Leads process improvements for the utilization management team to achieve cost-effective healthcare results and presents to senior leadership team.

9. Reviews, analyzes, and reports on utilization trends, patterns, and impacts to deliver an effective utilization program.

10. Leads and manages others in a matrixed/cross functional environment with tight timeframes and strict deadlines.

11. Ensures operational and regulatory compliance with all documentation and turnaround times for utilization management work queues across all product lines.

12. Optimizes utilization management workflows and prior authorization protocols across global capitation and traditional FFS reimbursement strategies.

13. Complies with all policies and standards.

14. Performs other duties as assigned.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Hybrid - remote and standard office environment.

SKILLS AND ABILITIES:

1. Working Knowledge of InterQual and/or Milliman Care Guidelines.

2. Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning.

3. Excellent written and oral communication.

4. Problem solving capabilities to drive improved efficiencies and customer satisfaction.

5. Attention to detail.

6. Proficiency with Microsoft Office.

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Company:

Cost Center:

Address:

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.