Director, Utilization Management

Accountable for providing vision and strategy for inpatient utilization and prior authorization management activities designed to achieve quality and service-driven objectives. Oversees all phases of development, organization, planning and implementation of projects/initiatives/workflows/processes to enhance quality-driven outcomes.

Essential Functions:
  • Provides direction and oversight to ensure effective management of inpatient care, discharge planning, and prior authorizations.
  • Optimizes processes and workflows to achieve successful quality outcomes and benefit maximization within the scope of responsibility.
  • Possesses the flexibility to act as a subject matter expert liaison for Clinical Services and/or a leader on cross-functional teams.
  • Serves as an instrumental partner in development of key performance indicators. Monitors and tracks key performance indicators to independently identify over/under utilization patterns and/or deviation from expected results.
  • Formulates strategic solutions to enhance quality outcomes.
  • Executes periodic competitor utilization management program comparison and analysis to ensure WellCare’s utilization management program maintains competitive edge.
  • Develops processes and procedures to ensure department-wide compliance with contractual, regulatory (Federal/State) and accreditation entities.
  • Provides leadership and support to front-line staff, supervisors and managers.
  • Leads talent management activities to develop and cultivate future leaders.
  • Promotes and improves environment of Provider and Health Plan partnership.
  • Ensures monitoring and tracking tools are in place to adequately link and assess production and quality driven work products and outcomes to individual performers.
  • Serves as the subject matter expert for inpatient and prior authorization management for future expansion and growth efforts
  • Develops formal policies, procedures and workflows that effectively guide work activity.
  • Develops formal department-specific new employee orientation and training programs.
  • Chairing monthly UM meetings.
  • Performs other duties as assigned.

This position is contingent upon the bid award in the state of New Hampshire to WellCare Health Plans, Inc.

Candidate Education:
  • Required A Bachelor's Degree in Nursing (BSN), Health Administration, Nutrition or business related field OR equivalent work experience
  • Preferred A Master's Degree in Business, Public Health or Healthcare administration
Candidate Experience:
  • Required 7 years of experience in acute clinical/surgical experience and/or behavioral health clinical setting
  • Required 3 years of management experience in a managed health care setting
  • Required Other current experience in utilization management to include pre-authorization, utilization review, concurrent review, discharge planning, and/or skilled nursing facility reviews
Candidate Skills:
  • Intermediate Demonstrated problem solving skills Independent problem solving to overcome barriers and meet deadlines
  • Intermediate Ability to work within tight timeframes and meet strict deadlines
  • Intermediate Ability to lead/manage others
  • Intermediate Demonstrated analytical skills
  • Intermediate Ability to work in a fast paced environment with changing priorities
  • Intermediate Demonstrated written communication skills
  • Intermediate Demonstrated interpersonal/verbal communication skills
  • Intermediate Ability to create, review and interpret treatment plans
  • Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
  • Intermediate Other Demonstrate effective critical thinking and decision making skills
  • Intermediate Other Ability to communicate on any level required to meet the demands of the position
  • Intermediate Other Ability to correctly write business letters and comprehensive reports

Licenses and Certifications:

  • Required Licensed Registered Nurse (RN)
  • Preferred Other Utilization review/management certification, or equivalent professional certification
Technical Skills:
  • Required Intermediate Microsoft Excel Proficient in Microsoft Outlook applications, including Word,Excel, Power Point and Outlook
  • Required Intermediate Microsoft Word Ability to use proprietary health care management system
  • Required Intermediate Microsoft Outlook
  • Required Intermediate Microsoft PowerPoint
  • Required Intermediate Healthcare Management Systems (Generic)
  • Required Intermediate Microsoft Visio

About us
Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.