Role Overview: Alameda Health System is hiring! The Director of Utilization Management holds a critical role encompassing operational oversight, strategic planning, compliance, and collaboration. Their responsibilities span from managing admissions to ensuring clean claims, identifying trends, and optimizing resource utilization. This role supports patient care coordination, fosters physician collaboration, and aligns with organizational objectives while adapting to ad hoc duties as needed. In essence, they orchestrate efficient utilization management to deliver high-quality patient care.
DUTIES & ESSENTIAL JOB FUNCTIONS : NOTE: Following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.
- 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.
- Perform 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
