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Our Values

Respect Belonging Accountability Transparency

Department

*Hybrid Work Schedule

Job Summary

The Senior Director of Health Plan Utilization Management is a senior leader for the Denver Health Medical Plan (DHMP) with responsibility for providing strategic and operational leadership for all utilization management functions across the organization. This area has unique regulatory and contractual compliance requirements for each line of business. This role is responsible for ensuring clinically appropriate cost-effective and regulatory-compliant medical necessity determinations while supporting high-quality member outcomes and provider collaboration. The Senior Director partners closely with Operations Network Management Quality Compliance and Finance to align utilization management strategy with organizational this capacity the Senior Director oversees multiple teams performing this work. The Director reports to the DHMP Chief Medical Officer and collaborates closely with them to develop update and implement the DHMP Utilization Management vision and strategy.

Essential Functions:

• Assures that all staff are appropriately trained on all relevant software programs and applications necessary to perform their job functions. (10%)
• Participates in presentation of reports to the Operations Team DHMP Board of Directors and other bodies as required. (10%)
• Attends and participates in Quality Management Committee DHMP Operations Team meetings Utilization Management Committee enterprise Care Coordination meetings and other related meetings and activities as required. (10%)
• Serves as an issue-related or escalation liaison between Utilization Management and other departments and/or agencies both within DH contractors and/or plan members. (10%)
• Oversees the maintenance development implementation and continuous improvement of UM policies and procedures and management of information systems to accomplish UM goals for all contracted populations. (10%)
• Develops analyzes and presents reports on productivity quality and outcomes. (10%)
• Ensures DHMP can provide documentation of compliance with contractual and regulatory requirements prior to audit by the State CMS DOI etc. (10%)
• Develops implements and evaluates formal educational activities and follows up on issues identified through educational activities. Brings new knowledge to staff meetings. (10%)
• Works closely with DHMP Compliance Officer to ensure all DHMP lines of business operational performance meets or exceeds regulatory requirements including but not limited to policies and procedures reporting. Acts as a voting member of the DHMP Compliance Committee. (10%)
• Ensures routine and ad hoc reporting available which may include utilization data by setting (inpatient outpatient and Pharmacy) or other special projects supporting the overall goals of DHMP. (10%)

Education:

• Masters degree required
• Graduation from an accredited educational program for Nursing or Physicians Assistants required

Work Experience:

• Seven years of experience in administration in managed care health plan administration or healthcare provider organizations required AND
• Minimum of five years of supervisory and management experience required AND
• 1-3 years Health Plan or healthcare experience with various lines of business including Medicare Medicaid CHP Exchange and/or Commercial Plans required AND
• 1-3 years Experience in managing vendors required required

Licenses:
Knowledge Skills and Abilities:

• Knowledge of regulatory and accreditation standards for health plan or healthcare operations required.
• Strong program development analysis and evaluation skills required.
• Demonstrated excellence in managing people and processes.
• Strong leadership skills with ability to engage multidisciplinary clinical and non-clinical teams to solve complex problems.
• Strong knowledge and experience in utilization principles concepts and strategies preferred.
• Ability to develop and maintain effective relationships with internal and external stakeholders.

Shift

Work Type

Salary

Benefits

At Denver Health we take care of the people who take care of our community. Our benefits are built to support your life your family and your future with generous paid time off fully paid parental leave exceptional retirement contributions comprehensive health coverage and nationally recognized well-being programs. We invest in your growth through tuition assistance career advancement pathways and professional development while also offering meaningful financial advantages through loan forgiveness eligibility and employer contributions. When you join Denver Health youre joining a mission-driven organization that invests in you.

Here is a small list of our benefit programs:

• Paid time off starting at 28 days per year inclusive of vacation personal/sick and 7 Holidays

• 100% paid parental leave up to 6 weeks

• Immediate eligibility for retirement plans with employer contribution up to 9.5%

• Generous medical dental vision plans in addition to employer paid disability and life insurance.

• Comprehensive well-being programs including on-site employee fitness center located on Denver Health main campus and nationally recognized RESTORE Center

• Free RTD EcoPass (public transportation)

• Childcare discount programs & exclusive perks on large brands travel and more

• Tuition reimbursement & assistance

• Education coaching and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer free student loan coaching and assistance navigating the PSLF program

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

About Denver Health

Denver Health is an integrated high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center a 555-bed acute care medical center Denvers 911 emergency medical response system 10 family health centers 19 school-based health centers Rocky Mountain Poison & Drug Safety the Public Health Institute at Denver Health Denver Health Medical Plan and Denver Health Foundation.

As Colorados primary and essential safety-net health care system Denver Health is a mission-driven organization that has provided millions in uncompensated care for the uninsured each year.

Located near downtown Denver Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas talents and contributions reflective of the needs of our community. All job applicants for safety-sensitive positions must pass a pre-employment drug test once a conditional offer of employment has been made. Applicants will be considered until the position is filled.