Job Summary

The Director, Utilization Management, is responsible for overseeing the direct patient utilization review process, ensuring appropriate levels of care, and managing payer relationships through a strategic blend of clinical judgment, administrative oversight, and planning. As a pivotal leader within the Care Management framework, specifically following the Triad Model which includes a RN care manager, social worker, and utilization management RN, this role will champion the development and integration of comprehensive patient care coordination plans. These plans serve as the foundation for coordinated care delivery across the healthcare continuum, from inpatient to outpatient services.

The Director will lead and direct utilization review functions for Harris Health with priority on concurrent and retrospective work to evaluate the medical necessity, appropriateness, and efficiency of the utilization of medical services procedures and facilities for all patients to ensure accurate patient status. This includes utilizing clinical knowledge, expertise and industry standard clinical guidelines carrying the responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity, while working to reconcile denials and reconsiderations, assist with appeals as needed and arrange peer-to-peer-level review while collecting, analyzing and addressing variances from the plan of care.

This role will also oversee the clinical affairs utilization of Outsourced Medical Services (OMS), ensuring that external providers deliver appropriate, high-quality patient care in alignment with Harris Health's clinical standards and cost objectives. The Director will work in tandem with the operational director of OMS to manage vendor partnerships, monitor utilization, and integrating OMS seamlessly into the patient's overall care coordination plan.

The Director requires a sophisticated blend of clinical expertise, administrative oversight, and strategic planning to influence Harris Health organizational policies and manage complex payer relationships effectively.

Minimum Qualifications

Degrees:
Master's degree in nursing, Healthcare Administration, Business Administration or Public Administration required
Bachelor's degree in nursing from an Accredited Nursing Program

Licenses & Certification:
Registered Nurse; Current, valid registration to practice in the State of Texas.
Specialty Care Management certification: American Case Management Association (ACMA) or Certified Case Manager (CCM) certification held upon hire or obtain within two (2) years.

Work Experience: Eight (8) years of experience in Healthcare environment in the acute care setting including utilization management; 3 years of case management experience or payer experience required.

Management Experience: Five (5) years supervisory experience

Communication Skills:
Exceptional Verbal (e.g., Public Speaking)
Writing /Correspondence
Writing /Reports
Above average Verbal Communication (Heavy Public Contact)

Proficiencies: MS Word, MS Excel

Job Attributes

Knowledge/ Skills/ Abilities:
Analytical, Medical Terms, Mathematics

Work Schedule: Flexible, Weekends, Holidays, Travel, On Call, On site/Hybrid with Telecommute eligibility

Other Requirements:
a. Outstanding communication and interpersonal skills, with the ability to build authentic relationships with a diverse set of high-profile stakeholders.
b. Proficiency, creativity and innovation in establishing and evaluating program process and outcome measures, with alignment to both organizational and programmatic mission and vision.
c. Demonstrate effective verbal and written communication skills in working with a diverse population of physicians, nurses, and support staff. Must partner with designated service line leadership.
d. Change Management
e. Must have effective leadership skills and be capable of motivating, recruiting and educating staff through program adaptations.
f. Proficient in developing and sustaining collaborative partnerships, through effective community engagement strategies.
g. Demonstrate knowledge and skill in resource management including budget and personnel practices.
h. Superior writing skills to compose grant proposals, course outlines, manuals and reports.
i. Demonstrate a working knowledge of personal computer operations and the ability to use word processing, spreadsheet, and database software in a Windows environment.
j. MS PowerPoint