Director of Utilization Management

About the role

MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage.

The Director of Utilization Review directs the department's activities and resources to ensure alignment with the mission, values, and objectives of the department and organization.

Responsibilities

• Develops and implements departmental strategic goals, plans, and standards consistent with the clinical, administrative, legal, and ethical requirements/objectives of the organization.
• Oversees compliance with regulations, laws, and ethics via audits and direct observation.
• Provides leadership in developing and implementing standardized tools, roles, and systems to support Utilization Review.
• Directs and evaluates departmental operations. Leads operational improvements to facilitate standardization of utilization review practices.
• Establishes metrics to achieve service targets.
• Oversees and evaluates programs and services focused on continuous quality improvement.
• Participates in review of contracts and agreement of services.
• Plans and monitors staffing activities, including hiring, orienting, evaluating, disciplinary, and continuing education initiatives.
• Develops a network of high-performing teams.
• Prepares, monitors, and evaluates departmental budgets, and ensures that the department operates within the allocated funding.
• Participates as an active management member representing the Utilization Review Department in collaboratively meeting operational, budget, and strategic planning goals.

Requirements

• Bachelor of Science Degree in Nursing, Business, or other Healthcare-related field. Master's Degree preferred.
• RN License through the State of Ohio.
• 10+ years of experience in clinical nursing and utilization management with at least 3+ years of utilization management experience at a Managed Care organization.
• Working knowledge of utilization review practices related to regulatory and accreditation requirements.
• Proven team leader with the ability to interact with all levels of staff members, physicians, and other healthcare providers.
• Ability to prioritize issues and solve complex problems.
• Proficient computer, written, and verbal communication skills including presentation skills.
• Innovative and self-directed.
• Demonstrates a high tolerance for ambiguity and change and provides leadership to adapt effectively to a changing environment.

Benefits

• Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.
• Retirement savings account with employer match starting on day one.
• Generous paid time off programs.
• Employee recognition programs.
• Tuition/professional development reimbursement starting on day one.
• RN to BSN tuition 100% paid at Mount Carmel’s College of Nursing.
• Relocation assistance (geographic and position restrictions apply).
• Employee Referral Rewards program.
• DailyPay: Eligible colleagues can see how much they’ve made every day and transfer their money any time before payday.
• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.

Mount Carmel, a member of Trinity Health, has been a transforming healing presence in Central Ohio for over 135 years, serving over 1.3 million patients annually.