Director, Medical Management & Utilization Review

Director of Medical Management and Utilization Review

Location: Alabama

Job Description

The Director of Medical Management & Utilization Review will provide oversight to the Utilization Review and Health Services Case Management departments. This position will travel to locations within the VIVA HEALTH service area through a reliable means of transportation insured in accordance with Company policy.

Key Responsibilities

• Work with Clinical Services to make appropriate medical review decisions. Responsible for oversight of the Medical Management (MM) and Health Services Case Management (HSCM) departments and the day-to-day operations to ensure that departmental goals and objectives are in line with corporate goals.
• Assist in the ongoing evaluation of current strategies, as well as the formation of new strategies, to reduce health care costs and deliver quality care to our members.
• Responsible for the day-to-day management of the MM and HSCM staff supervisory staff, monitoring work performance, production, and providing clinical and administrative support.
• Oversee and ensure that all medical criteria utilized by the team is evidence based, approved by Utilization Management/Quality I I Improvement (UM/QI) Committee and meets all regulatory requirements.
• Monitor metrics relating to utilization and authorization, approval and denial rates, and timeframes to ensure compliance with all state and regulatory requirements.
• Oversee training and auditing of MM and HSCM personnel to ensure adherence to departmental and corporate policy.
• Ensure staff is providing quality customer service to our members and providers.
• Participate in internal and external committees and meetings as necessary, including but not limited to quarterly UR and QA committee meetings.
• Responsible for the development and/or revision of MM and HSCM policies. Ensure related policies and procedures are written and maintained in accordance with Company policy.
• Interface with all departments and their staff to provide and receive updates on any changes in procedures or processes.
• Work with the Development team on development and maintenance of the VIVA HEALTH UM system to test, integrate, and create applications for the systems. Assist with department training on new applications.
• Assist with the coordination of continuing education and training seminars for department staff.
• Perform other duties as needed.

REQUIRED:

• Graduate of an accredited program of professional nursing, ADN/BSN
• 5 - 7 years clinical experience in an acute-care setting
• 3 - 5 years in utilization review/case management and/or quality improvement
• 3 - 5 years in a managerial or supervisory position
• Current RN License in good standing with the State of Alabama Board of Nursing
• Valid driver's license in good standing

PREFERRED:

• Master's degree in healthcare related field