Director Utilization Management

Location:

Avera Health Plans

Worker Type:

Regular

Work Shift:

Primarily days with possible weekends/evenings/holidays (United States of America)

Position Highlights

You Belong at Avera

Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

A Brief Overview

Accountable for oversight and execution of utilization review initiatives and strategies associated with utilization metrics. This position is responsible for providing leadership and strategic oversight for medical and domestic network utilization and clinical evidence-based guideline adherence reviewing key performance utilization and quality metrics and establishing and measuring employee performance and productivity metrics. This position will lead various projects and approach each in a critical problem-solving manner while organizing leading and developing teams to execute solutions. This position is responsible for providing leadership of a well-rounded team of nurses and healthcare staff all aimed to facilitate the appropriate delivery of health care products and services in a cost-effective efficient manner to improve quality of care and health outcomes. The Director of Utilization Management will need to be knowledgeable in various aspects of all health plan lines of business inclusive of commercial marketplace government and self-funded clients. The position requires interaction with health system stakeholders key leaders vendors delegated entities healthcare providers policy makers and accreditation and government organizations.

What you will do

• Work directly with the applicable leadership to provide operational oversight of clinical review services.
• Support ongoing review of utilization management processes to best align with organizational strategic initiatives.
• Monitors trends related to internal performance and vendor delegation.
• Develop key clinical operational and financial metrics for the health plan committees and leaders.
• Reviews key clinical and operation data to ensure the Health Plans National Committee for Quality Assurance (NCQA) audit readiness and data integrity.
• Ensure integration of managed care principles into population health management initiatives.
• Develop utilization management quality programs to meet plan CMS and accreditation body requirements.
• Complete regulatory submissions and ensure compliance with CMS NCQA and internal Health Plan policies for all utilization management quality programs.
• Promotes financial stewardship through use of ethical business principles and applies to effective cost management revenue generation and risk mitigation.
• Designs systems of care that enhance the member experience.
• Responsibilities include interviewing hiring developing training and retaining employees; planning assigning and leading work; appraising performance; rewarding and coaching employees; addressing complaints and resolving problems.

Essential Qualifications

The individual must be able to work the hours specified. To perform this job successfully an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others hear understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge skills and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions as long as the accommodations do not cause undue hardship to the employer.

Required Education License/Certification or Work Experience:

• Associates in Nursing with advanced education and/or UM experience.
• 4-6 years Clinical nursing experience
• 4-6 years Experience in formal leadership.

Preferred Education License/Certification or Work Experience:

• Bachelors in Nursing.
• Masters in Business Administration Healthcare Administration Healthcare Management or equivalent.
• 1-3 years Utilization management or managed care experience

Expectations and Standards

• Commitment to the daily application of Averas mission vision core values and social principles to serve patients their families and our community.
• Promote Averas values of compassion hospitality and stewardship.
• Uphold Averas standards of Communication Attitude Responsiveness and Engagement (CARE) with enthusiasm and sincerity.
• Maintain confidentiality.
• Work effectively in a team environment coordinating work flow with other team members and ensuring a productive and efficient environment.
• Comply with safety principles laws regulations and standards associated with but not limited to CMS The Joint Commission DHHS and OSHA if applicable.

Benefits You Need & Then Some

Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportunities to help live balanced healthy lives. Benefits are designed to meet needs of today and into the future.

• PTO available day 1 for eligible hires.

• Up to 5% employer matching contribution for retirement

• Career development guided by hands-on training and mentorship

Avera is an Equal Opportunity Employer - Qualified applicants will receive consideration for employment without regard to race color religion sex national origin disability Veteran Status or other categories protected by law. If you are an individual with a disability and would like to request an accommodation for help with your online application please call 1- or send an email to .