JOB SUMMARY:Responsible for the coordination and management of a full-service Utilization Management program to service the TDCJ, TJJD and other contracted inmate populations.
Scope:Contribute to the success of UTMB and the (CMC) Correctional Managed Care Organization through the effective management of the CMC Utilization Management Program.
ESSENTIAL JOB FUNCTIONS:- Organize a staff of professionals to perform all aspects of both Utilization Review and Case Management in the Utilization Management Program.
- Oversee the orientation program of staff to the Utilization Management methods, review, and the documentation process.
- Acts as a resource to medical and security personnel at the prison level to the managed care process.
- Oversee an ongoing quality assurance/ quality improvement program for the Utilization Management Department.
- Responsible for the development of all the reporting and documentation needs for the Utilization Management Program.
- Develop and maintain an ongoing process to evaluate and modify the Utilization Management program.
- Continuous monitoring and improvement of reporting and documents to reflect the department's productivity, patient population and opportunities for improvement and predictive analysis.
- Responsible for the twenty-four-hour operation of the department to provide services to the CMC patient population.
- Ensure effective fiscal responsible use of resources.
- Adheres to internal controls and reporting structure established for department.
- Performs other related duties as required.
KNOWLEDGE/SKILLS/ABILITIES:- Strong data analysis skills
- Performance Improvement expertise
- Flexible and adept at managing a changing work environment.
- Superior people skills to interact with varied agencies, departments, and healthcare providers.
- Outstanding prioritization and organizational skills
SUPERVISION:Received: VP, Inpatient CMC & Admin Hospital Galveston
Given: UR Program Manager, Business Systems Analyst
BUDGET RESPONSIBILITY:Direct: Responsible for the fiscal year department specific budget for CMC Utilization Management.
Indirect: Responsibility of the department budget has a direct effect on the overall CMC budget.
DECISION-MAKING RESPONSIBILITY:Decisions include:
- Department personnel
- Department budget
- Development and continued review of department policies and procedures
- Quality and process improvement
- Data Analytics and recommendations to improve delivery of services.
- Effective use of evidence-based criteria in the continued performance of department Utilization Management.
EQUIPMENT:Standard office equipment.
WORK ENVIRONMENT:Standard office environment. May be required to work within the confines of a prison, jail, or juvenile detention center.
Security clearance is required; pre-employment drug testing is also required.
REQUIRED EDUCATION/EXPERIENCE:- Graduate of accredited Registered Nursing program
- Minimum of five years' clinical experience in adult medical health care
- Minimum of five years management experience in healthcare.
- Minimum of four years of utilization management experience
- Master's degree (may be in non-related health care field).
REQUIRED LICENSES, REGISTRATIONS OR CERTIFICATIONS- Current unrestricted Texas RN License
PREFERRED EDUCATION/EXPERIENCE:- Master's degree in Nursing, Healthcare Administration, Business Administration, Public Health, or related field.
- Current CCM, ACM, CPHQ, or equivalent utilization management/quality certification.
- Five (5) or more years of progressive leadership experience in utilization management, case management, managed care, or healthcare operations.
- Experience in correctional healthcare, academic medical centers, or large integrated healthcare systems.
- Advanced experience with InterQual and healthcare analytics platforms.
- Demonstrated expertise in performance improvement, physician engagement, and utilization optimization initiatives.
- Lean Six Sigma certification preferred.
- Proven success leading large multidisciplinary teams and complex healthcare operations.
PREFERRED LICENSES, REGISTRATIONS OR CERTIFICATIONS- Certification for performance improvement
Salary is commensurate with years of relevant work experience.
