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Health Services WellCare - Health Services Leadership Careers

Utilization Management - Director Job

Full Job Title: Director, Utilization Management

Job Number: 1605244

Location: Atlanta, GA

Date Posted: 3-31-2017

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.

DEPARTMENT: Health Services

REPORTS TO: Sr. Medical Director

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.

Candidate Education:
  • Required a Bachelor's Degree in Nursing (BSN), or equivalent work experience
  • Preferred a Master's Degree in Nursing
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 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 demonstrate effective critical thinking and decision making skills
  • Intermediate ability to communicate on any level required to meet the demands of the position
  • Intermediate 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) in state of practice
  • Preferred Utilization review/management certification, or equivalent professional certification
Technical Skills:
  • Required intermediate Microsoft Excel
  • 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

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Last Updated On: 12/9/2015