Director, Utilization Management

Role Overview

The Director of Utilization Management at Alameda Health System plays a critical role in operational oversight, strategic planning, compliance, and collaboration. They oversee a team of utilization review professionals, monitor and evaluate healthcare service utilization, analyze data, develop policies, foster communication, and participate in quality improvement initiatives.

DUTIES & ESSENTIAL JOB FUNCTIONS

• Lead and manage a team of utilization review professionals providing guidance, training, and performance evaluations.
• Monitor and evaluate the utilization of healthcare services, including appropriateness, efficiency, and medical necessity of treatments and procedures.
• Analyze data and generate reports on utilization trends, outcomes and quality indicators to support decision-making and process improvement initiatives. Reports to appropriate committees.
• Manage quality of performance criteria, policies and procedures, and service standards for the utilization management operations. Evaluate utilization reviews and determine program improvements.
• Develop and implement utilization review policies and procedures in accordance with industry standards and regulatory requirements.
• Direct and coordinate data gathering and record keeping legally required by federal and state agencies, the Joint Commission, and hospital policies; participates in the risk mitigation, process of implementing new or revised processes, and projects.
• Foster effective communication and collaboration with internal departments, external agencies, and insurance providers to facilitate the utilization review process.
• Participate in interdisciplinary committees and meetings to contribute to the development and implementation of quality improvement initiatives.
• Oversees the secondary review process; actively appeals denied cases when necessary and assists physicians with appeals. Maintains minimal denial rates by Medicare, MediCal, private and contracted payers through appropriate direction of utilization practices; assists physicians and hospital personnel in understanding UM matters.
• Performs all other duties as assigned.
• Prepares cost analysis reports and other data needed for the preparation of the departmental budget.
• Provides in-house educational programs as needed for both staff and physicians.
• Responsible for the recruitment, orientation, evaluation, counseling and disciplinary action of UM and administrative staff.
• Serves as a content expert to staff and internal departments and external partners; networks with other hospitals, nursing organizations, and professional organizations to keep abreast of changes within the profession.

Minimum Qualifications

• Required Education: Bachelor’s degree in Nursing
• Preferred Education: Master’s degree in Nursing
• Required Experience: Three years of utilization review experience. Health insurance company and/or acute care hospital, post-acute and psych; three years of InterQual and/or MCG. Strong clinical nursing background.
• Required Licenses/Certifications: Valid license to practice as a Registered Nurse in the State of California.
• Preferred Licenses/Certifications: UM / CM certifications