Director of Utilization & Benefit Management

JOB SUMMARY/PURPOSE

Responsible for delivering operational oversight for the Utilization Management (UM), Behavioral Health (BH), Social Determinants of Health (SDOH), Health Related Social Needs (HRSN), and Health Equity (HE) teams. Ensures the delivery of medically necessary, cost-effective, and high-quality care through evidence-based UM processes that fully comply with CMS, OHA and other contractual requirements while ensuring that health equity goals are identified and addressed. Fulfills the role of the designated Health Equity Administrator and oversees all health equity initiatives including the Community Health Assessment (CHA), Community Health Improvement Plan (CHIP), and the Health Equity Plan (HEP). Drives clinical and operational excellence across the teams responsible for all UM, BH, SDOH, HRSN, HE functions, including prior authorizations, concurrent reviews, and service requests. Provides oversight of engagement with key community partners including the social care infrastructure. Works closely with executive leadership, Behavioral Health leadership, community partners, counties within the service area, and state agencies.

EXPERIENCE/EDUCATION/QUALIFICATIONS

• Bachelor’s degree required. Master's degree in a related field preferred.
• Current unencumbered Oregon RN license required.
• Five (5) years of leadership experience in utilization review, case management, quality improvement, or a related healthcare area required.
• Experience in the following required:
• Managed care and specialty healthcare organizations.
• Regulatory compliance.
• EHRs.
• Data analytics.
• Technology integration.
• Healthcare operations.
• Process optimization.

KNOWLEDGE/SKILLS/ABILITIES

• Leadership - Inspires, motivates, and guides others toward accomplishing goals. Achieves desired results through effective people management.
• Conflict resolution - Influences others to build consensus and gain cooperation. Proactively resolves conflicts in a positive and constructive manner.
• Critical thinking – Identifies complex problems. Involves key parties, gathers pertinent data and considers various options in decision making process. Develops, evaluates and implements effective solutions.
• Communication and team building – Leads effectively with excellent verbal and written communication. Delegates and initiates/manages cross-functional teams and multi-disciplinary projects.