The Director, Utilization Management is responsible for the operational management and directional guidance of the Alliance Utilization Management Department activities including Inpatient & Outpatient Utilization Management (UM), Long Term Care, (LTC) and state sponsored/state directed programs. The Director is knowledgeable of and responsible for compliance with regulatory requirements of Managed MediCal regulation for inpatient and outpatient services, Nursing Facility (NF-B)/Sub-Acute Facility (NF-A)/Distinct Part of Hospital (DP-H,) ICFs, IMDs, long term care admissions, continued stay requirements, as well as transitions of care to community settings.

Principal responsibilities include:

• Collaborate with Medical Directors of UM and CM in development and design, and responsible for implementation of UM (outpatient, acute, LTC) strategic plans and ongoing operations.
• Responsible for ensuring optimal staffing for UM (outpatient, acute, LTC) to ensure operational efficiency and compliance.
• Work closely and in collaboration with all clinical staff to maintain open communication among all the clinical departments and create the team culture.
• Responsible for developing, monitoring, improving, and evaluating all operational and technical issues with clinical UM (outpatient, acute, LTC) teams.
• Identify trends, patterns, and opportunities for improvement in NF A&B/DP-H, develop action plans on opportunities, and communicate findings to appropriate Alliance committees
• Lead and direct activities related to implementation of all UM (outpatient, acute, LTC) initiatives and the UM aspects of CalAIM initiatives.
• Collaborate with AAH Leaders implementing CalAIM and Behavioral Health initiatives to support their fidelity to UM processes and procedures across all clinical services.
• Collaborate with Director of Social Determinants of Health (CM) on areas of overlapping responsibility including TOC & community supports
• Monitor and implement solutions for appropriate medical utilization and create actionable information for staff members
• Provide leadership to UM/LTC managers to ensure production of UM (outpatient, acute, LTC) standard work and documentation to support successful state/federal audits and NCQA survey outcomes.
• Provide leadership on initiatives to develop action plans on successful transitions of care, and readmission reduction.
• Act as liaison with all other departments.
• Provide leadership to plan-wide initiatives relating to utilization of medical services and coordination of care across settings, with particular focus on Long Term Care Services.
• Ensure the development of evidence and documents for external entities, such as DMHC/DHCS audits and NCQA surveys, which include requirements in Title XXII and CDPH. Documents include updated P&Ps, workflows, file universes, source documents, and any other requirements.
• Oversee internal audits which include regular case audits, analyze results, and execute corrective action plans (CAP) to address any identified issues.
• Develop detailed corrective action plans that clearly identify the corrective actions steps required, timeframes, and individuals responsible for corrective action.
• Collaborate with Quality Management on CalAIM Population Health Management strategies for UM and LTC aspects.
• Support with clinical initiatives other departments, such as Quality, Information Technology, Provider Services, and Project Management Office.
• Keep up to date on standards and regulations established by CMS, DMHC, DHCS, NCQA, CDPH, Knox-Keene and Title XXII.
• Ensure compliance with quality programs and applicable regulatory agency requirements.
• Perform all job functions with integrity. Provide timely internal and external customer service in cooperative, professional, and respectful manner.
• Coordinate, direct and approve all budgets for utilization management, retrospective review, and Long-Term Care.
• Ensure systems are in place to monitor and correct areas not meeting budget.
• Analyze all utilization reports to ensure medical expenditures are appropriate and utilization targets are met.
• Participate in development and implementation of integration strategies for Medi-Cal UM/ LTC with strategic partners in Alameda County, in partnership with Senior Director, HCS and CMO/Medical Directors.
• Partner with Senior Director, HCS, UM MD and Hospital networks to lead hospital Length of Stay and readmission strategies.
• Perform other duties, projects or functions as assigned.
• Ensure that the UM/LTC departments maintain up to date procedures, activities, and processes to ensure regulatory compliance

ESSENTIAL FUNCTIONS OF THE JOB

• Overseeing services of Utilization Management, Long Term Care, Transitions of Care (in collaboration with Director of Social Determinants of Health,) California Children’s Services, and community-based adult services.
• Overseeing and managing select clinical programs, especially pertaining to utilization management and Long-Term Care services.
• Mentor leadership staff in medical management and implementation of clinical programs.
• Supervising and training UM/LTC leadership staff.
• Serve as subject matter expert in UM and LTC for medical management and clinical programs in support of the Triple Aim of improving patient experience of care, health outcomes, and reducing overall cost.
• Communicating effectively and efficiently internally and externally.
• Conducting oral presentations to teams, health leadership and stakeholders.
• Leading and participating in internal and external committees and meetings.
• Complying with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
• Overseeing Manager/Supervisors on daily services of Utilization Management and Long Term Care
• Developing data analysis for program evaluation strategies and use outcomes of data analysis to drive initiatives pertaining to UM/ LTC.

PHYSICAL REQUIREMENTS

• Constant and close visual work at desk or on the computer.
• Constant sitting and working at desk.
• Extensive typing using keyboard and/or mouse.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, instant messaging, email, or in person.
• Occasional lifting of folders, files, binders, and other objects weighing between 0 and 30 lbs.
• Frequent walking and standing.
• Occasional driving of automobiles.

Number of Employees Supervised: 3-5

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

• Active and current California Registered Nurse license required
• Bachelor’s degree in a health care related field required.
• Advanced management or business degree preferred.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Six years healthcare related experience
• Three years of experience in managed care setting required.
• 4 years of experience in utilization management required.
• Two years of experience in management of Long Term Care services required.
• Five years of experience in a management position required.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• In depth understanding of utilization management/ LTC standards and clinical care best practices.
• Excellent written and verbal communication skills required.
• Experience with Medi-Cal program, Department of HealthCare Services, Department of Managed HealthCare, National Committee for Quality Assurance, Knox-Keene, CMS, CDPH, and Title XXII.
• Ability to use and manipulate reported data to assess department metrics.
• Knowledge of applicable standards and regulations pertaining to Utilization Management and Long Term Care programs for DHCS, DMHC, NCQA, CMS, Knox-Keene, CDPH, and Title XXII.
• Familiarity with HMO, IPA, and medical group contracting concepts, principles, and practices.
• Experience in use of various computer system software including pharmacy programs, as well as Windows, Word, Excel, Outlook, and PowerPoint.
• Experience supervising personnel performing utilization management and Long Term Care activities.
• Skill in data analysis and strategic planning.

Salary Range: $160,989.86 - $241,484.79/Annually