Director, Utilization Management (remote)

Summary of Position

Work across the enterprise to ensure effective process and management of utilization management, implement strategic process improvements, as well as provide analytical evaluation of appropriateness and efficiency of medical necessity. Serve as an integral strategic partner for ongoing monitoring and improvements of the use of health care services and procedures. Evaluate and help build the clinical functions of inpatient care management, concurrent review, prior authorization, discharge planning, along with all non-clinical functions. Drive a reduction in denials, improve member care, and reduce provider abrasion. Demonstrate the ability to handle multiple priorities as well as the ability to articulate and represent EmblemHealth's strategy to executive leaders across the enterprise and external partners. Work with Senior Leadership to define and monitor Utilization Metrics while collaborating with Clinical Administration partners on deployment strategies. Develop course correction strategies to address Utilization Metrics that fail to meet performance standards; work closely with Corporate Compliance to ensure all Federal, and State Regulations as well as NCQA Requirements and Corporate Policies related to prospective, concurrent, and retrospective review processes are embedded in the service level agreements with our vendors.

Principal Accountabilities

• Drive UM operational performance for each core process and align with EmblemHealth strategic objectives.
• Collaborate with leadership to establish best practices for ensuring operational control with an effective process for monitoring critical performance metrics. Ensure compliance with Medicare Advantage program and/or NCQA standards, as well as state and federal regulatory requirements.
• Work internally and in tandem with Provider Collaboratives and outsourced vendors, to identify and implement integrated care coordination and population health management strategies that maximize all available skills and resources to improve members' health care experience, reduce medical expense and improve quality outcomes.
• Ensure that department workflows and policies/desktop procedures are aligned and accurate at all times.
• Communicate and collaborate with internal stakeholders including but not limited to Clinical Administration, G&A, Compliance and Product as needed to share data/trends, promote change, achieve optimal performance, and support overall EmblemHealth strategic and tactical objectives. Be proactive and clear (use Executive Briefing Tool).
• Advise leadership on improvement opportunities regarding medical expense programs and clinical activities that impact service delivery.
• Responsible for utilization review, risk management, and quality assurance of medical programs to ensure the judicious use of the facility's resources while providing high-quality care.
• Provide clinical and workflow management oversight direction for design, development, testing and implementation of software applications used to support Clinical Operations.
• Drive to raise the bar in outcomes by partnering with and developing the skills and medical management capabilities of physician organizations and partnerships.
• Support the Quality and Pharmacy departments to sustain HEDIS STARS.
• Work closely with the Manager of Compliance to proactively prepare for investigations, audits, etc.
• Foster a collaborative environment and continuously coach and mentor direct reports to achieve higher levels of Medical Management competencies.
• Ensure a high performing work culture is embedded within the departments.
• Identify and address gaps for developing competencies.
• Continually assess activities and processes to ensure efficiency, effectiveness, and added value.