Department: Jackson Health System - Utilization Management
Address: 1611 NW 12 Ave., Miami, FL
Shift details: Full Time, Days
Why Jackson:
Jackson Health System is a nationally and internationally recognized academic medical system offering world-class care to any person who walks through our doors. For more than 100 years, Jackson has evolved into one of the world's top medical providers for all levels of care, no matter if it's for a routine patient visit or for a lifesaving procedure. With more than 2,000 licensed beds, we are also proud of our role as the primary teaching hospital for the University of Miami Miller School of Medicine.
Here, the best people come together to deliver Jackson's mission for our diverse communities. Our employees are committed to providing the best CARE by demonstrating compassion, accountability, respect, and expertise in everything we do.
Summary
The Director, Utilization Management is responsible for leading and shaping the utilization management strategy while providing management oversight in implementing, directing and monitoring the escalation, conversions, LOC reviews etc. The incumbent acts as a subject matter expert, and provides executive level advice and guidance on the Department's functions and overall business operations.
Responsibilities
Leads the development of utilization management strategy by leveraging the use of data/analytics to inform and technology solutions to streamline operational efficiencies.
Builds a cost -benefit methodology to rationalize decisions on utilization reviews to be performed based upon staffing costs, productivity, and projected medical cost savings.
Identifies opportunities to create efficiencies in the utilization management program and activities, incorporating innovative approaches and solutions, and leading process redesign work necessary to implement improvements.
Directs the utilization management, concurrent review and functions.
Provides leadership in the design and implementation of utilization management policies, processes and procedures needed to meet National Commission on Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC) accreditation requirements for both a Medi-Cal and Medicare line of business (D-SNP).
Establishes and measures productivity metrics in order to support workforce planning methodology and rationalization of services to perform utilization management reviews.
Reviews and reports out on utilization review trending.
Ensures quality of services through utilization review, review of medical records and provider education, while identifies training opportunities and trends.
Designs, develops, implements and maintains programs, policies and procedures in order to meet regulatory, contractual, accreditation, and performance standards.
Facilities within the system to identify opportunities related to LOC and preventing denials.
Maintains knowledge of regulatory and accreditation agencies and related requirements pertinent to case management and integrated behavioral health, such as Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), Department of Managed Health Care (DMHC).
Oversees the utilization review preparations and responses to regulatory audits and the construction of corrective action plan.
Participates in regulatory audits related to all aspects of utilization management.
Tracks, analyzes, and develops strategies to address outlier performance of utilization metrics and reports on metrics at a regular cadence.
Participates in strategic planning and implementation of the utilization development's operational goals related to the growth and development of business operations.
Conducts complex research and analysis related to utilization management strategies.
Models and promotes effective interdepartmental communication. Prepares narrative and statistical reports and makes presentations.
Drafts, recommends, and implements administrative policies and processes and procedures related to utilization management operations.
Monitors legislative and legal changes related to utilization management functions and ensures appropriate communication.
Reviews and assesses overall department functions, core work, goals and structure.
Develops and implements short- and long-term planning to achieve strategic objectives, and completes an annual department assessment.
Oversees, coordinates or participates in a variety of DPC.
Develops and manages department operations and budget.
Provides support to CMOs and CM directors. Collaborates with the Medical Director team on complex cases.
Directs, manages and supervises department staff.
Ensures staff maintains up-to-date knowledge, skills and abilities related to the administration of assigned responsibilities and functions Identifying.
Oversees and assists with objectives, priorities, assignments, tasks, and reviewing work products as needed.
Provides mentoring, coaching, and development and growth opportunities for staff and subordinate managers and supervisors.
Evaluates employee performance, provides feedback to staff, and counsels or disciplines staff when performance issues arise.
Performs all other related job duties as assigned.
Experience
Generally requires 5 to 7 years of related experience. Management experience is required.