Director Utilization Management
Company: Crozer-Keystone Health System
Posted on: February 23, 2021
FR =Full-time Regular , 1 =Day Shift , 8:30am-5:00 pm Job
Summary: The Director, Utilization Management (UM) leads and
directs the utilization review staff and functions for the
organization. The Director, UM identifies policies and procedures
that incorporate best practices and ensure effective utilization
reviews that meet required timeframes. The Director, UM is
responsible for the daily management and oversight of major lines
of utilization (inpatient, skilled nursing facilities, procedures,
radiology etc.), and prior authorizations for Coordinated Regional
Care's (CRC) delegated lines of business. The Director, UM, manages
and monitors concurrent and retrospective reviews to ensure that
the patient is receiving the right care in a timely, high-quality,
and cost-effective manner. The Director, UM will lead interaction
with Crozer Health Hospital Care Management and UM staff to educate
hospital Care Management, UM staff, and providers about health
plans, NCQA, CMS/PA State, and Medical Group best practices and
regulations. The Director will develop quarterly and annual plans
in consultation with the Chief Medical Officer, Medical Director,
and practice physicians to improve utilization of effective and
- Develop and promote a fully-integrated approach to UM to
include prior authorization and concurrent/retrospective reviews
while improving quality of care and managing ER/IP costs and
reduction in overall costs.
- Oversee a team of UM nurses and coordinators to execute and
improve UM processes. Stay closely involved in day-to-day process
to understand and improve UM processes and ensure team fulfills
- Manage and monitor UM processes to ensure compliance with PA
State and NCQA or payor mandated timeframes for authorization
determinations, as well as patient and physician verbal and written
- Develop and enhance programs to optimize collaboration between
internal and external nurse case managers and primary care
physician staff to achieve enterprise medical management targets
and to meet departmental objectives and metrics.
- Ensure compliance with all applicable regulatory and
accreditation guidelines such as NCQA, CMS, and PA Health Choices
- Responsible for meeting timeframes for UM report generation and
- Mentor direct reports to meet department and company
- Facilitate and lead scheduled Utilization Management Committee
- Attend Crozer Health and Hospital JOC's when requested and
ensure action items are followed-up and resolved.
- Attend and participate in operational or interdepartmental
meetings a requested. Develop policy and procedures as required for
- Complete special projects when required or needed.
Qualification Requirements: To perform this job successfully, an
individual must be able to perform each essential duty
satisfactorily. This job description reflects management's
assignment of essential functions; it does not prescribe or
restrict the tasks that may be assigned. The requirements listed
below are representative of the knowledge, skill, and/or ability
required. Reasonable accommodations may be made to enable
individuals with disabilities to perform the essential functions.
Ability to demonstrate effective critical things and
decision-making skills. Demonstrate ability to manage multiple
priorities within time constraints. Stays focused with pressure.
Strong written and verbal communication skills.
Education/Experience: PA license eligible Registered Nurse with
minimum of 5-10 years' experience in managed care or Health Plan
environment; preferred Utilization Management, Quality Improvement,
Inpatient Program, and Health Plan Incentive program experience.
Deep understanding of the UM process, statutory and regulatory
requirements, and UM Appeal/Grievance processes. Experienced with
Health plan guidelines and Interqual criterion, PA State
guidelines, and community guidelines and practices. Strong
background in UM in acute hospital setting and Emergency
Department. PA license must active and in good standing at time of
hire. Knowledge/Skills/Abilities: Strong computer skills, data
entry, and proficient in Word, Excel, Access, Power Point. Proven
success in working and managing employees in a UM operation. Strong
leadership skills in managing UM related work group and achieving
organizational goals. Strong independent decision-making,
influencing and analytical skills. Extensive knowledge of state and
federal laws and regulations governing medical agencies. Strong
organizational and problem solving skills. Ability to work
effectively under pressure by prioritizing work activities.
Maintains member confidence and protects operations by keeping
claim and patient information confidential in compliance with HIPAA
Keywords: Crozer-Keystone Health System, Springfield , Director Utilization Management, Executive , Springfield, Massachusetts
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