Director, Utilization Management

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PacificSource is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

Lead the respective managers and teams in the ongoing internal and external health services operations as related to Utilization Management processes across lines of business and departments. Responsible for Utilization Management, across all Lines of Business (LOBs), and the Special Functions (SF) team for Quality Assurance, Case Management (CM), and Utilization Management (UM). Facilitate, guide, create, and monitor data and relevant analytics for ongoing operations and regulatory oversight bodies, across Utilization Management and Special Functions team. Provide oversight of audit processes and assist in identification and resolution of gaps and compliance issues. Lead the teams in process changes to effectively improve our internal and external customer service and provide leadership and direction to the teams through the promotion and use of LEAN project management principles. Work collaboratively with internal and external entities in the implementation of quality improvement measures and UM process transformation initiatives.

Essential Responsibilities:

• Manage and improve the performance of the Utilization Management department through effective oversight and coaching, managing team performance, monitoring workflows, cross-department collaboration, and improving processes and outcomes.
• Monitor and evaluate performance for the teams relating to volumes, timelines, accuracy, customer service, and other performance objectives, including regulatory compliance, across UM.
• Responsible for employee engagement scores across LOBs. Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.
• Oversee and assist in providing exceptional service and information to members, providers, employers, agents, and other external and internal customers.
• Standardize systems, processes, and policies across departments, where feasible. Continually seek to improve quality of service, care, and processes for internal and external customers.
• Responsible for process improvement and working with other departments to improve interdepartmental processes. Utilize LEAN methodologies for continuous improvement. Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.
• Identify costs and benefits of Utilization Management programs inter- and intra-departmentally.
• Participate in compliance activities, audits and reporting. Support related PacificSource departments, facilitate audit processes, and assist in the identification and resolution of gaps.
• Ensure internal departmental awareness, inclusion, and deployment of relevant CMS, Oregon Health Authority, National Committee for Quality Assurance (NCQA) and other relevant regulatory bodies’ rules and guidelines.
• Serve as liaison with all PacificSource departments to coordinate optimal provision of service and information.
• Participate in management planning, Request for Proposals (Medicare/Medicaid applicable oversight), oversight of completion of annual reports as required by states we serve.
• Ensure that benefits are administered consistently to meet contract obligations and to ensure regulatory compliance.
• Oversight of Prior Authorization grid on a bi-annual basis, including determining expected return on investment.
• Oversight of and collaboration with Compliance and Product Development in the development of handbooks, contracts and benefit summaries.
• Accountable for accurate reinsurance and/or stop loss and large case reporting to reinsurer, Executive Management and Medical Director(s). Accountable for identification of complex/potential reinsurance cases and Medical Director notification.
• Maintain oversight of applicable quality regulations and certifications. Remain current in specialty field and keep apprised of current and anticipated trends in UM needs.
• Maintain excellent working knowledge of Medicare and Medicaid Governmental rules and regulations as well as those applicable to the Commercial LOB, to ensure that project operations remain compliant.
• Responsible and accountable for operational excellence through management reports, up-to-date systems, and execution on strategic initiatives.
• Oversight of the development of policies, procedures, guidelines, and other operational protocols for UM teams. Inform the development, monitoring and implementation of pertinent policies and procedures for Health Services within CMS, Patient Protection and Affordable Care Act (PPACA), NCQA, Health Insurance Portability and Accountability Act (HIPAA) and State/Federal requirements.
• Oversight of caseloads and workflows of all teams to assure appropriate distribution and processing of tasks.
• Evaluate and recommend systems additions and upgrades as appropriate. Work with Information Technology (IT), Facets Business Systems (FBS), and Analytics on the prioritization of software changes and needed Informatics upgrades.
• Actively participate in various strategic and internal committees and disseminate information within UM and represent company philosophy.
• Act as primary liaison with Commercial and Government operations. With Medical Directors, act as liaison and resource for Provider-Payer partnerships. Actively pursue partnerships and build relationships with key healthcare stakeholders in the communities served by PacificSource.
• Work collaboratively with the Case Management Director and Senior Director to ensure seamless care transitions across the care continuum and to establish best practice strategies for managing members across LOBs.
• Responsible for oversight, management, development, implementation, and communication of department programs. Develop annual department budgets to include UM and SF teams. Monitor spending versus the planned budgeted throughout the year and take corrective action where needed.
• Oversight of UM contracts, their data, and required reporting to meet regulatory and business needs.
• High-level oversight of SF team’s claims editing process to ensure accuracy of billing and coding.
• Work and coordinate with Marketing and Communications with preparation and review of member – facing communications.

Supporting Responsibilities:

• Collaborate with Medical Directors in responding to inquiries or complaints and pertinent report preparation for other review functions.
• Actively participate as a key team member in Manager/Supervisor meetings.
• Participate in and support project teams led by other departments and provide necessary input to support the goals of colleagues.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: At least seven (7) years of experience with varied medical exposure required. Minimum of 3 years management or supervisory experience required. Experience with Medicaid and Medicare clinical operations in health plans is required. Experience in case management, disease management, utilization management and program development using evidence-based medicine required. Experience in Medicare bid process and benefit design is preferred. Prior success in healthcare integration, process development and program implementation is desirable.

Education, Certificates, Licenses: Bachelor’s degree in health services administration or related field required. Registered nurse with current unrestricted state license required. Maintains current clinical knowledge base and specialty nurse functions. Case Manager Certification as accredited by CCMC preferred.

Knowledge: Knowledge and understanding of disease prevention, medical procedures, care modalities, procedure codes (including ICD-10 and CPT codes,), health insurance, and Centers for Medicare and Medicaid Services (CMMS)/ State of Oregon mandated benefits. Ability to develop, review, and evaluate utilization reports. Knowledge of and demonstrated experience with quality improvement methodology. Experience developing and delivering presentations. Organizational skills with solid experience in using computers and various software applications including Microsoft Office Suite, SharePoint, Claims and Care management programs, and audio-visual equipment. Ability to work independently with minimal supervision. Ability to deal with members and families at all levels of care and/or crisis. Thorough knowledge of community services, providers, vendors, and facilities available to assist members. Ability to supervise and manage a regular staff and a professional nursing staff. Continually seeks to improve quality of service, care, and processes for internal and external customers.

Competencies

Authenticity

Building Organizational Talent

Coaching and Developing Others

Compelling Communication

Customer Focus

Empowerment/Delegation

Emotional Intelligence

Leading Change

Managing Conflict

Operational Decision Making

Passion for Results

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 30% of the time.

Skills:

Accountable leadership, Business & financial acumen, Empowerment, Influential Communications, Situational Leadership, Strategic Planning

Compensation Disclaimer

The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.

Base Range:

$102,577.62 - $179,510.82

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.

• We are one team working toward a common goal.

• We are each responsible for customer service.

• We practice open communication at all levels of the company to foster individual, team and company growth.

• We actively participate in efforts to improve our many communities-internally and externally.

• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.

• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.