Director of Utilization Management

Integra Partners; United States; Remote; USD 144,000 - 176,000; Full time

Benefits offered by this job

Competitive compensation and annual/bi

401(k) retirement program with company

Company-paid life insurance

Short term disability coverage

Medical, Vision, Dental benefits

PTO

Paid Parental Leave

Sick Time

Holidays and floating holidays

Quarterly events

Health and wellness programs

Career development opportunities

Job summary

Integra Partners seeks an experienced Director of Utilization Management to lead clinical and non-clinical UM teams for a managed care organization. You will drive UM program delivery to health plan clients, grow the UM business, and collaborate with leadership to operationalize robust UM processes.

You will manage audits, QA, and NCQA certification efforts, develop staffing models, and work with account managers to meet contractual performance.

Qualifications

• Bachelor’s degree in area of specialty is preferred.
• Analytical ability and clinical knowledge to assess medical records and trends.
• Strong written and verbal communication for cross-functional collaboration.

Responsibilities

• Direct clinical and non-clinical UM teams for a managed care organization.
• Develop and operationalize UM programs in collaboration with executives.
• Ensure timely reviews, authorizations, and appeals with QA and NCQA alignment.
• Lead quality improvement activities and audits of medical criteria.
• Oversee staffing models and policies for scalable operations.

Skills

Analytical ability

Communication skills

Interpersonal skills

Education

Bachelor’s degree in area of specialty, preferred

Job description

Integra’s Utilization Management (UM) division is looking for an experienced individual to direct the clinical and non-clinical utilization management teams for a managed care organization. This individual will play a key role in delivering UM to our health plan clients, growing our UM business, and working with the organization to operationalize our UM program.

JOB QUALIFICATIONS: KNOWLEDGE/SKILLS/ABILITIES

The Director of Utilization Management’s responsibilities include but are not limited to:

• Prepare and maintain Utilization Review Plan policies and procedures
• Obtain or maintain certification or license in states when performing Utilization Review
• Work with Chief Medical Director to establish, adopt, and review UM benefit and medical necessity decision-making criteria
• Manage UM Department, clinical and non-clinical staff, to ensure timely review of prior authorizations and appeals
• Responsible for UM-related quality improvement activities, including conducting audits to ensure consistent application of medical criteria, evaluating program for improvement opportunities and annual IRR testing
• Communicate and work with company executives and management to ensure alignment of UM program with departments and corporate initiatives
• Participate on Quality Improvement Committee and UM Committee to oversee clinical oversight of UM Department
• Work in conjunction with Account Managers and external liaison for clients to ensure program meets contractual delegated activities and performance requirements
• As needed, represent the UM team in support of client-facing efforts such as business development and/or business review activities.
• Help consult on existing and/or prospective client UM programs
• Participate in technology related activities and implement solutions across UM Department
• Oversee and execute the workplan to maintain NCQA certification
• Build and manage the administrative and clinical resources to ensure the UR program functions efficiently and effectively, meeting all internal, legal, regulatory, and/or certification standards
• Build and maintain a staffing model that is flexible and appropriate to scale as the business scales
• Manage internal policies and procedures and workflows to ensure compliance, effectiveness, and best in class clinical operations
• Owner of the third party technology and configuration of medical management software to ensure optimal operation
• Responsible for day-to-day team management to ensure on-time, on-budget delivery of all operations · As needed, represent the UM team in support of client-facing efforts such as business development and/or business review activities
• Help consult on existing and/or prospective client UM programs

WHAT WILL YOU LEARN IN THE FIRST 6 MONTHS?

• In the first six months you will learn the function of the UM department within the organization and be fully integrated in your position, company, and team
• You will have a full and complete understanding of our metric requirements and reporting capabilities
• You will understand your role and responsibilities, to foster excellence in team performance
• You will develop team goals and monitor progress, as you build relationships with your team to encourage and understand their needs and abilities
• During this time, you will set measurable goals for personal development and growth

WHAT WILL YOU ACHIEVE IN THE FIRST 12 MONTHS?

• You will create a people first approach to your team, easily identifying the strengths and weakness of each team member and how to best support them
• You will be contributing your skills and knowledge to meet your department’s metrics and goals

EXPERIENCE:

• Bachelor’s degree in area of specialty, preferred
• Minimum of 10 years of UM management experience in a managed care setting
• Experience with UM NCQA or URAC certification/accreditation
• Experience with leading and managing teams of clinical and non-clinical staff
• Analytical ability and clinical knowledge in order to assess medical records, identify trends, and report findings
• Communication skills, verbal and written, needed to convey information clearly and consistently
• Interpersonal skills necessary to develop and maintain a wide variety of cooperative working relationships

Salary:$160,000.00/Annually

Benefits Offered

• Competitive compensation and annual bonus program
• 401(k) retirement program with company match
• Company-paid life insurance
• Company-paid short term disability coverage (location restrictions may apply)
• Medical, Vision, and Dental benefits
• Paid Time Off (PTO)
• Paid Parental Leave
• Sick Time
• Paid company holidays and floating holidays
• Quarterly company-sponsored events
• Health and wellness programs
• Career development opportunities

Remote Opportunities

We are actively seeking new colleagues in: Arizona, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Kentucky, Massachusetts, Michigan, North Carolina, Nevada, New Jersey, New York, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Washington.

Our Story

Founded in 2005, Integra Partners is a leading national durable medical equipment, prosthetic, and orthotic supplies (DMEPOS) network administrator. Our mission is to improve the quality of life for the communities we serve by reimagining access to in-home healthcare. We connect Payers, Providers, and Members through innovative technology and streamlined workflows affording Members access to top local Providers and culturally competent care. By focusing on transparency, accountability, and adaptability, we help deliver better health outcomes and more efficient management of complex healthcare benefits.

With a location in Michigan plus a remote workforce across the United States, Integra has a culture focused on collaboration, teamwork, and our values: One Team, Drive Results, Push the Boundaries, Value Others, and Build Community. We’re looking for energetic, talented, and dedicated individuals to join our team. See what opportunities we have available; there may be a role for you to engage in a challenging yet rewarding career in healthcare. We look forward to learning more about you.

Integra Partners is an equal opportunity employer. We are committed to providing reasonable accommodations and will work with you to meet your needs. If you are a person with a disability and require assistance during the application process, please don’t hesitate to reach out. We celebrate our inclusive work environment and welcome members of all backgrounds and perspectives.