• Director, Utilization Management

    Location US-CA-Commerce
    Job ID
  • Overview

    The Utilization Management Director (UMD) position is responsible for the development and implementation of AltaMed’s utilization management strategic plan, by providing leadership, direction and support for Utilization Management (UM) functions that focus on the evaluation of medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan and in compliance with industry regulatory provisions as they pertain to UM delegation.


    The UMD provides oversight of the utilization review staff and determines policies and procedures that incorporate best practices in conducting concurrent reviews, prior authorizations and or retrospective activities that are predicated on ensuring member care coordination is conducted timely, in the right setting, and is cost-effective and quality driven. UMD leadership is incumbent on providing a functional UM infrastructure that is fundamentally driven through staff education, training and the provision of adequate resources to effectuate optimal outcomes in productivity and excellence. The Director measures UM activities outcomes through the application of innovative strategies and analytics to support the measurement of UM trends, patterns, and impacts to resources to validate they are meeting UM goals and objectives.



    1. Develop UM goals and objectives in accordance with companystandards.
    2. Assist in coordinating integration between medical management delegated activities, IPA and contracted Health Plan.
    3. Monitor and analyze the managed care operations productivity and quality while providing ongoing feedback and education for the staff.
    4. Assist in coordinating integration between medical management delegated activities, IPA and contracted Health Plan. Monitor and analyze the productivity and quality of these managed care operations while providing ongoing feedback and education for the staff.
    5. Plans, directs and monitors the utilization management program(s). Provides advice, counsel, feedback and coordination to promote a collegiality between staff, physicians and the leadership team.
    6. Ensures that development of care coordination across the continuum leads to outcomes supportive of industry standards.
    7. Designs and implements processes to ensure appropriate care coordination in accordance with quality and safety.
    8. Provides direction for performance measures to attain optimal clinical, operational, financial and satisfaction outcomes.
    9. Directs the collection, analysis and presentation of data on utilization patterns and outcomes.
    10. Manages the financial and capital resources for UM services by monitoring operating revenue and expenses, establishing and maintaining cost control programs and developing and implementing new or revised programs and/orservices.
    11. Provides oversight of all referral/authorization, of prior authorization, inpatient concurrent review and retrospective reviews.
    12. Develops and implements strategies to work with all external customers to ensure appropriate reimbursement.
    13. Develops and oversees the department budget in conjunction with corporate goals andobjectives.
    14. Perform all other related duties as assigned.

    Prior Authorization

    1. Ensures timely ongoing authorization requests review in alignment with health plan contractual requirements and regulatory mandates
    2. Ensures appropriate usage of resources to facilitate the UM process
    3. Identifies opportunities for process improvements necessary to facilitate department functions
    4. Handles escalated cases either internally or those referred by contracted providers.
    5. Works closely with Regional Medical Directors to manage business need for UM operations
    6. Assists with the review and development of new protocols, procedures and guidelines
    7. Participates in onsite and webinar CMS/health plan audits as subject matter expert on UM policies, standards and compliance for UM operations
    8. Responds timely to corrective action plans and all follow-up activity
    9. Works closely with all clinical personnel making UM decision to ensure compliance with application of medical necessity and benefits interpretation
    10. Works closely with leadership on UM initiatives to ensure regulatory compliance


    1. Responsible for the oversight of concurrent reviews for medical necessity per evidenced based criteria, appropriateness of service and level of care and validated through UM documentation practices of assigned staff
    2. Responsible for ensuring the concurrent review process is conducted timely and in accordance with regulatory standards,
    3. Responsible for overseeing staff functions supporting timely arrangements for transitions to higher or lower level of care
    4. Responsible for ensuring that the concurrent process includes referring cases that require clinical consultation with the Medical Director in a timely manner and per assigned rounds schedule,
    5. Responsible for implementing systems and processes that support identifying outliers and preparing documentation as well as reports on potential quality of care issues as identified.
    6. Serve as the liaison between hospitals, IPAs, vendors, outside agencies, and providers to ensure effective communication and collaboration in an effort to support an effective review processes throughout the institutional continuum of care,
    7. Ensure the privacy and security of PHI (Protected Health Information) as outlined in company policies and procedures relating to HIPAA compliance.



    1. Bachelor’s degree in Nursing preferred, plus a minimum of five years’ experience in managed care at the hospital or insurance industry level with at least 2 years of experience in a supervisory capacity or its’ equivalent required.
    2. Experience in managing employees in remote locations highly desirable.
    3. Current valid license as a registered nurse through the California Board of Registered Nursing required.
    4. Knowledge of clinical care practices, operations and local, state and federal regulatory standards.
    5. Experience with E.H.R. and utilization management IT systems highly desirable.
    6. Knowledge of UM Policy and Program development and application required.



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