• Director, Utilization Management (RN)

    Job Locations US-VA-Glen Allen
    Job ID
    2018-4931
  • About Us

    Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.
    By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.
     
    At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.
     
    If this sounds like you, read on!

    Overview

    This position is responsible for providing oversight to the daily functions of the utilization management staff and monitoring staff performance in accordance with the VPHP policies and procedures.  Additional responsibilities include coordinating, conducting and documenting simple to complex Health Servies projects and operational procedures and identification of process. Also responsible for creating a strategic vision, processes tools, and procedures to assure ongoing visibility to operational performance of the department and company. 

    Medical Management educates members and empowers them to become active participants in their coordinated health care plans. This team of knowledgeable professionals in their field provide services to include Utilization Review, Medical Outreach, Case Management, Disease Management, Credentialing, Social Work as well as Grievance and Appeals.

    Responsibilities

    • Provides clinical and operational oversight of each Utilization Management initiative which includes utilization management and the analysis of clinical data to drive performance improvement.
    • Assist Directors of Care Management and Health Services with reviews and revisions to Utilization Management program descriptions annually or as indicated by contract or accreditation requirements.
    • Assist Directors of Care Management and Health Services with annual evaluations of Utilization Management programs per contract or regulatory requirements.
    • Identifies, assesses, develops, and implements cross-functional, cross-departmental work processes that impact various departments or the company to improve clinical outcomes.
    • Identifies opportunities to improve clinical care, customer service and internal business processes.
    • Collects, reports, trends, and analyzes Utilization Management program elements for departmental productivity and performance outcome reporting.
    • Provide expert assistance or best practice advice for team members.
    • Responsible for assessment, planning, implementation, tracking, monitoring, coordination, reconciliation and evaluation of the managed care members' performance across the continuum of care to include the complete transition of care to outpatient care.
    • Validates Utilization Management quality audit results for accuracy and individual developmental needs.
    • Develops staff performance objectives based on identified improvement or developmental opportunities and aligns with organizational performance outcome objectives.
    • Works closely with other managers and co-workers in order to ensure project deliverables are met in a timely and efficient manner.
    • Develops, implements, and monitors policies and procedures for contract and accreditation compliance.
    • Provides high level consultation to senior leaders for performance revisions integrations, and conversions, health-care strategies, product development, policy and procedure changes and/or cost control opportunities. 
    • Drives initiatives in the management team and organizationally that contribute to long term operational excellence.
    • Maintains strict confidentiality of member, provider company and personnel information.

    Qualifications

    MINIMUM EDUCATION REQUIRED

    • Minimum of five (5) years of clinical nursing experience is required
    • Current, unrestricted RN license in the Commonwealth of Virginia
    • Bachelors of Science required, Masters preferred

    SPECIAL KNOWLEDGE AND/OR SKILLS

    • Highly motivated individual with the ability to work independently as well as part of a team
    • Excellent verbal and written communication skills
    • Knowledge of NCQA and HEDIS
    • Demonstrated knowledge of Care Management principles
    • Strong analytical problem-solving, time management, and organizational skills
    • Proficient Microsoft Office product computer skills

    WORK BACKGROUND/EXPERIENCE

    • Minimum of five (5) years of clinical nursing experience
    • Minimum of five (5) years of management experience in a managed care environment
    • Knowledge of medical terminology

    PHYSICAL REQUIREMENTS

    • Physical health sufficient to meet the ergonomic standards and demands of the position.

     

    Equal Opportunity Employer All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

     

    Our mission is to inspire healthy living within the communities we serve!

     

     

     

     

     

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