DIRECTOR UTILIZATION MANAGEMENT

Location
Englewood, CO
Salary
Competitive
Posted
Aug 25, 2017
Closes
Sep 19, 2017
Specialty
Managerial
Contract Type
Permanent
Hours
Full Time
FullWell believes in approaching healthcare differently. We inspire and empower care teams to deliver the highest quality, highest value care to people in our communities. We believe in helping all people live their fullest lives.



FullWell is an independent population health company owned by Centura Health. We are a collaborative, physician-centric organization focused on bringing tools, resources and competencies to Colorado Health Neighborhoods (CHN) providers to deliver health care solutions that meet consumer needs while helping them make critical decisions across the entire care continuum.



Join FullWell; a health-focused, results-oriented, innovative organization that is on the leading edge of how healthcare is changing. Learn more at FullWell.com.

Job Description/Job Posting ID: 112223

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Position Summary

Responsible for oversight, management and optimization of all utilization management activities related to the referral delivery programs. Provides leadership to managers and staff directly responsible for the daily operations of the Utilization Management program. Participates in the development, implementation and maintenance of the referral process to ensure that patient and provider expectations are met or exceeded and ensures continuity by utilization of appropriate resources within the parameters of FullWell, health plan benefits and established contracts.

Minimum Education Requirements

Bachelor’s degree from a four-year college and/or a professional certification requiring formal education beyond a two-year college or equivalent experience.

Advanced degree in Health Administration, Public Health, Nursing Administration or related area preferred.

Minimum Experience Requirements

7 years of experience in the medical field.

5 years management experience in a medical group, IPA or health insurance plan.

Previous responsibility or experience in UM, medical management and medical claims review.

Experience in data analysis.

Previous fiscal / budgetary accountability. Page 2 of 7 Dir Utilization Management

License/Certifications

Colorado RN license - preferred but not required

Position Duties (essential functions denoted with an * )

 Commitment to support FullWell’s belief statement: FullWell believes in approaching healthcare differently. We inspire and empower care teams to deliver the highest quality, highest value care to people in our communities. We believe in helping all people live their fullest lives.*

 Consistently exhibits behavior and communication skills that demonstrate a commitment to superior customer service, including quality, care and concern with each and every internal and external customer.*

 Develops and coordinates strategies for ensuring the delivery of care in the most appropriate setting.*

 Identifies and participates in the development and implementation of UM program components, including referral policies and procedures.*

 Interfaces directly with FullWell’s health plan clients, UM staff, network practitioners, contracted vendors and other department leads.*

 Maintains referral turnaround times, as well as meeting and/or exceeding parameters set by FullWell, the health plan, State/Federal regulatory agencies and NCQA.*

 Ensures compliance with organization policies, State/Federal regulations and accrediting and regulatory bodies.*

 Assures contracted providers are utilized by collaborating with the Contracting team to obtain new contracts for specialty and ancillary services to meet the needs of the patients, while also tracking and notifying the FullWell Contracting team of gaps in the network.*

 Monitors provider referral patterns for appropriate utilization of specialty and ancillary services.*

 Responds to customer inquiries related to UM Processes and appeals.*

 Monitors high risk/high utilizing patients in regard to referrals and identifies and facilitates appropriate referrals to supportive programs.*

 Analyzes Referral Reports and identifies trends and makes recommendations to the appropriate governing team regarding interventions to improve utilization patterns. *

 Fosters organizational and system changes to improve departmental efficiency and effectiveness with respect to staffing by improving the outcome of referral management programs.*

 Identifies opportunities for the development of new referral management approaches including processing of referrals and preparation of proposals with cost analysis.*

 Participates in and supports organizational committees, as appropriate.*

 Provides input and leadership to electronic Referral Management System enhancements and implementation. *

 Coordinates projects and performs activities as delegated by the organizational committees and FullWell leadership.*  

 Participates in Joint Operations Committee (JOC) meetings with contracted health plans, as requested.*

 Facilitates ongoing and annual review and revision of the UM Programs, including the preparation of documents for annual and ad hoc audits and responses to corrective actions.*

 Works collaboratively with the Care Coordination management team to share best practices and ensure that appropriate processes are in place to maintain compliance with regulatory bodies.*

 Develops and manages a UM-specific business plan and budget along with the FullWell leadership team.*

 Motivates and leads the referral staff in setting and reaching goals for continuous improvement.*

 Provides training, supervision, guidance, and mentoring to managers and staff reporting to this position.*

 Identifies and develops content and oversees the educational needs of referral management staff, providers, inclusive of nurses, coordinators and physician reviewers.*

 Uses, protects, and discloses FullWell patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.*

 

Important notification to applicants as of Nov. 20, 2014: Effective Jan. 1, 2015, FullWell will no longer hire tobacco users in Colorado and Kansas. The change to our policy does not apply to associates hired on or before Dec. 31, 2014. FullWell is an Equal Opportunity Employer, M/F/D/V. 

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