Utilization Management Director - Inpatient (Hybrid)

PURPOSE

The Director Utilization Management (Inpatient) provides strategic leadership of the inpatient utilization management team and is responsible for the design, assessment, implementation and outcomes of inpatient utilization management strategies using a multidisciplinary approach to enhance member engagement, improve access to quality care and the use of cost-effective health resources.

Essential Functions

• Administers policies and procedures of inpatient services.
• Determines eligibility of programs ensuring compliance with board approved regulations.
• Maintains relationships with providers who provide services to patients and pursues a responsive system for authorization of services and approved claims.
• Oversees retrospective reviews, case appeals, billing coordination, and clinical support.
• Ensures that staff is fully trained and competent on standards of practice of Utilization Management, reimbursement methodologies and treatment coding.
• Directs the strategic and the day-to-day activities of the Department, including coaching and guiding individuals and teams in order to implement departmental, divisional, and organizational mission/goals.
• Recruits, retains and develops a high performing team.
• Evaluates performance of each team member, generates development plans and sets goals within the context of the corporate policies and procedures.
• Develops annual goals, and prepares, monitors, and analyzes variances of departmental budgets in order to control and appropriately allocate resources.
• Maintains relationships patterns, such as demographics of service, revenue, and expenditures by preparing statistical reports.
• Presents status of key performance indicators and makes recommendations on continuous improvement opportunities to the executive leadership team.

Education Level

Bachelor's Degree in Nursing OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Licenses/Certifications

Upon Hire Required Health Services\RN - Registered Nurse - State Licensure and/or Compact State Licensure.

Experience

• 8 years' Experience in a clinical and utilization review roles.
• 3 years' Management experience.

Preferred Qualifications

The ideal candidate will have led inpatient utilization management function in payor organization with a working knowledge of Guiding Care or similar platform.

Knowledge, Skills And Abilities (KSAs)

• Proficient in standard medical practices and insurance benefit structures.
• Proficient in utilization management processes, standards, and managed care.
• Knowledge of medical-necessity decisions (i.e., inpatient, acute, outpatient, hospice care).
• Experience in use of web-based technology and Microsoft Office applications such as Word, Excel, and Power Point.
• Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate performance, and implement strategies to improve individual and team-based performance as needed.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
• Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range

$135,040 - $250,668

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Federal Disc/Physical Demand Note

The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs. Physical Demands The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.