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WellCare - Health Services Leadership Careers

Utilization Management - Senior Director Job

Full Job Title: Sr Director, Utilization Management

Job Number: 1802613

Location: Tampa, FL

Date Posted: 6-5-2018

Department: Population Health Solutions

Reports to: VP, Medical Management HS Administration

Location: 8715 Henderson Road, Tampa FL 33634

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)

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Last Updated On: 12/9/2015