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Director of Utilization Management

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MetroPlus Health PlanNew York, NY
  • As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus' network includes over 27,000 primary care providers, specialists and participating clinics.
  • For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
  • Position OverviewThe Director of UM is responsible for providing hands-on operational expertise and leadership to the company's utilization management services.
  • In addition, the Director of UM acts as a strategic partner to the Senior Director of Clinical Services in the innovation, design, and implementation of new strategies to continue to improve operationsand clinical services.
  • The Director of UM is responsible for collaboratively enhancing MetroPlus' utilization management capabilities and execution through the development of strong management relationships with other areas within, and outside, the Medical Management Department, including but not limited to Customer Services, MedicareOperations, Exchange Operations, Claims, Compliance, MIS, Finance, and Regulatory Affairs.
  • Designing, implementing and administering industry best practices for utilization management program, and instilling Continuous Process Improvement across all teams and services within UM are all an ongoing priority for this position.
  • Assist the Sr. Director of Clinical Services in meeting department goals by coordinating business activities in the areas of budget, personnel, and space management.
  • Translate and reinforce the MetroPlus' strategic priorities, targets, and objectives across the Utilization Management team.
  • Develop, review, implement and oversee effective administration of Utilization Management workflow and processes in accordance with contract compliance as well as regulatory and accreditation requirements.
  • Supervise and evaluate the activities and effectiveness of Utilization Management activities.
  • Build a high-functioning team that meets all operating goals, including quality, efficacy, and cost of health care, administrative expense, customer service, performance improvement, regulatory requirement satisfaction, and staff engagement.
  • Monitor staffing patterns to meet Utilization Management functional needs to assure clinical input to the decisions made in the process of Utilization Review.
  • Provide day to day oversight of Team Leader activities to ensure utilization review activities are conducted timely meeting NYS DOH and CMS regulatory standards.
  • Monitor operations and implement strategies that promote compliance with regulatory standards.
  • Assure that all clinical adverse determinations for utilization review are appropriately reviewed and signed by a physician.
  • Provide clinical support and education as necessary to all UM staff.
  • Provide mentoring and coaching to direct reports to build and strengthen Utilization Management effectiveness.
  • Ensure regular departmental staff meetings are conducted and action items and follow-up issues are completed.
  • Partner with other Departments to develop, implement, and monitor system-wide performance improvement initiatives for Utilization Management measures.
  • Coordinate with other operational departments to identify and achieve workflow improvements to gainprocess and procedure efficiencies and create standardized reporting across all functional areas.
  • Work with all disciplines to maintain quality patient care and meet company contractual obligations, professional standards, and accreditation requirements.
  • Represent the health plan at regulatory meetings held by the New York State Department of Health, the New York City Department of Health and Mental Hygiene and managed care trade organizational meetings as necessary.
  • Establish/maintain working relationships with all functional areas to ensure thorough follow-up and completion of projects and issues.
  • Evaluate effectiveness of utilization management through analysis of defined metrics and recommend enhancements and/or improvements to facilitate consistent, cost-effective and proactive utilization management.
  • Identify and recommend opportunities for cost savings while improving the quality of care across the continuum.
  • Help in developing, analyzing, and maintaining key performance indicators which could impact staffing levels, quality of services, revenues, or expenses.
  • Ensure Utilization Management policies and procedures are consistent and compliant with Federal, NYS regulations and URAC utilization management standards.
  • Assist the Sr. Director of Clinical Services to ensure that strategic plans, goals, and financial targets are implemented within each business unit in Utilization Management to support the growth and fiscal solvency of the plan.
  • Conceive and implement management processes centered on accountability and effectiveness.
  • Develop and implement robust performance and operational metrics for all processes and products, to include outcome metrics for specific products.
  • Identify, design and implement Process Improvement opportunities that support utilization management operations.
  • BS/BA degree required with prior leadership experience in managed care or health insurance environment.
  • Nursing degree and/or Health care management (MBA, MPH, MHS, MHA) degree preferred.
  • Requires a minimum eight to ten (8 - 10) years of Utilization Management experience with a health plan
  • Requires broad clinical knowledge with good clinical background, analytical and decision-making skills.
  • 5+ years of successful management experience in a managed care with Medicaid, Medical and Commercial Lines of Businesses.
  • Experience with managed care audits and reviews required.
  • Experience with Quality Assessment and Process Improvement (QAPI) projects required.
  • Demonstrated experience with writing and implementing program level policy and procedures required.
  • Experience applying medical management treatment guidelines, such as InterQual, Milliman, or other practical management guidelines required.
  • Ability to lead and manage significant change.
  • Should possess performance driven management style.
  • Ability to implement performance matrix and outcomes matrix.
  • In depth knowledge of all aspects of managed care medical management including UM/CM, Grievance and Appeals, medical policy, clinical claims review (professional and facility), and delegated vendor oversight.
  • Strong leadership skills are a prerequisite, including excellent interpersonal, communications, problem solving and negotiating skills.
  • Ability to work cross-functionally and collaboratively across the MetroPlus leadership team.
  • Ability to think strategically and act tactically.
  • Professional CompetenciesIntegrity and TrustCustomer FocusFunctional/Technical skillsWritten/Oral Communication
  • Associated topics: administrative assistant, administrative coordinator, administrative staff, administrative support, asso, associate, document, facilities, operational support, records management

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