Director Utilization Management

St Luke's Health; Houston (TX); On-site; USD 130,000 - 190,000; Full time

Job summary

Baylor St. Luke’s Medical Center is seeking a senior Utilization Management Director to lead the market development, implementation, and evaluation of the UM program within the CommonSpirit Health Care Coordination model.

The role directs staff, ensures compliance with payer requirements, drives accreditation readiness, and partners with the Division Director Care Coordination to achieve organizational goals.

Qualifications

• Bachelor's degree in Nursing, Health Care Administration or advanced clinical degree.
• Minimum 3 years of clinical case management (Utilization Management, Denial Management, Care Coordination).
• 5 years of progressively responsible management experience.
• Extensive operational experience in managed care; program planning, staff development, and needs assessment.
• Comprehensive knowledge of utilization management and payer/regulatory requirements.

Responsibilities

• Lead market development, implementation, evaluation and direction of the Utilization Management Program.
• Oversee UM policies, procedures and processes; ensure accreditation activities and regulatory compliance.
• Direct staff to meet performance standards and align with payer requirements and organizational goals.

Skills

Clinical case management

Management experience

Operational experience

Care coordination

Education

Bachelor's degree in Nursing, Health Care Administration or advanced clinical degree

Job description

Job Summary and Responsibilities

The Utilization Management (UM) Director is responsible for the market(s) development, implementation, evaluation and direction of the Utilization Management Program and staff in support of the CommonSpirit Health Care Coordination model. The Utilization Management department processes authorizations, inpatient admission and continued stay reviews, retrospective authorizations utilizing standardized criteria to determine medical necessity; reviews and processes concurrent denials that require medical necessity determinations; processes appeals and reconsiderations. In collaboration with the Division Director Care Coordination, the UM Director develops strategies to achieve departmental and CommonSpirit Health goals and objectives. This position directs the UM staff to meet or exceed operational performance standards. The Director oversees development and implementation of UM policies, procedures and processes; directs and assists with accreditation activities; efficient management of payer requirements, addressing denials effectively, and compliance with payer and regulatory requirements, and reviews and analyzes UM program outcomes and quality metrics.

Job Requirements

Required:

• Bachelor's degree in Nursing, Health Care Administration or advanced clinical degree.
• Minimum 3 years of clinical case management (Utilization Management, Denial Management, Care Coordination)
• 5 years of progressively responsible management experience
• Extensive operational experience in managed care; extensive experience in program planning, implementation, staff
  development, and needs assessment
• Comprehensive knowledge of utilization management, financial management that includes revenue cycle, Medicare, Medicaid,and commercial admission and review requirements.

Where You'll Work

Baylor St. Luke’s Medical Center is an 881-bed quaternary care academic medical center that is a joint venture between Baylor College of Medicine and CHI St. Luke’s Health. Located in the Texas Medical Center, the hospital is the home of the Texas Heart® Institute, a cardiovascular research and education institution founded in 1962 by Denton A. Cooley, MD. The hospital was the first facility in Texas and the Southwest designated a Magnet® hospital for Nursing Excellence by the American Nurses Credentialing Center, receiving the award five consecutive times. Baylor St. Luke’s also has three community emergency centers offering adult and pediatric care for the Greater Houston area.