Sr. Director, Utilization Management

Department: Population Health Solutions

Reports to: VP, Medical Management HS Administration

Location: 8715 Henderson Road, Tampa FL 33634

Additional possible locations: Houston, TX, Phoenix, AZ

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/work flows/processes to enhance quality-driven outcomes. Oversees utilization management and discharge planning for all markets that are not self-contained. Works collaboratively with the market medical directors, presidents and nurse executives to ensure consistency in our review process.

Essential Functions:
  • Provides direction and oversight to ensure effective management of inpatient care, discharge planning, and prior authorizations for medical or behavioral health.
  • Optimizes processes and work flows 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 Health 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 work flows that effectively guide work activity.
  • Develops formal department-specific new employee orientation and training programs.
  • Provides direction on a corporate level for the interface between EMMA and Excelys so that authorizations can map to claims.
  • Responsible for expanding UM on a regional basis.
  • Responsible for assessing the market's need for onsite concurrent review, working collaboratively with the market to place the staff in facilities.
  • In collaboration with our UM Medical director and VP, assists in identifying and then implementing strategies to correct trends of either over or under utilization.
  • Serves as a key member in the Clinical Services Organization's leadership team.
  • Collaborates with operations to decrease turnaround times on authorization requests coming through the intake unit.
  • Collaborates with appeals and grievances to identify issues with current authorization processes and to identify trends which could improve application of criteria and processes.
  • Chairs a monthly Utilization Management meeting with representatives from all lines of business to identify and resolve issues impacting members, providers and claims payment.
  • Ensures that we are actively engaging on Medical Director reviews and strategies when an external review source is needed so that timely medical determination can be made.
  • Oversees UM portion of readiness reviews, External Quality Review Organization (EQRO) reviews and NCQA reviews for the markets managed by corporate UM.
  • Serves as the primary resource for determining our future UM processes for the PEGA system conversion.
  • Performs other duties as assigned.
Additional Responsibilities:
    Candidate Education:
    • Required A Bachelor's Degree in Nursing (BSN), Health Administration, Business, or related field
    • Required or equivalent work experience
    • Preferred Other MBA, MPH or MHA
    Candidate Experience:
    • Required 7 years of experience in acute clinical/surgical experience
    • Required 5 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
    • Required 5 years of experience in in progressively challenging positions
    Candidate Skills:
    • Advanced Demonstrated problem solving skills Independent problem solving to overcome barriers and meet deadlines
    • Advanced Ability to work within tight timeframes and meet strict deadlines
    • Advanced Ability to lead/manage others
    • Advanced Demonstrated analytical skills
    • Advanced Ability to work in a fast paced environment with changing priorities
    • Advanced Demonstrated written communication skills
    • Advanced Demonstrated interpersonal/verbal communication skills
    • Advanced Ability to create, review and interpret treatment plans
    • Advanced Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
    • Advanced Other Demonstrate effective critical thinking and decision making skills
    • Advanced Other Ability to communicate on any level required to meet the demands of the position
    • Advanced Other Ability to correctly write business letters and comprehensive reports
    Licenses and Certifications:
    A license in one of the following is required:
    • 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 Microsoft Visio
    • Required Intermediate Healthcare Management Systems (Generic)

      About us
      Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. 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.