Director, Utilization Management Operations

CareSource; Dayton (OH); On-site; USD 136,000 - 237,000; Full time

Job summary

CareSource in Dayton, OH seeks a Director of Utilization Management Operations to lead UM projects, ensure regulatory compliance, and advance department initiatives including program descriptions and procedures.

You will work with clinical teams, monitor performance, drive standardized evidence-based practices, and oversee readiness for new programs while developing workflows and partnering across the organization.

Qualifications

• Bachelor’s Degree or equivalent years of relevant work experience.
• Master’s degree in Health Care Administration preferred.
• Minimum of five (5) years medical management operations, leadership, program, or management experience is required.
• Minimum of one (1) year Utilization Management experience preferred.
• Experience implementing programs with focus on integration is preferred.
• Experience with Medicaid, Medicare, Commercial and Managed Care is preferred.

Responsibilities

• Manages and prioritizes UM and related projects, and ensures timeliness and adherence to completion.
• Responsible for gathering and prioritization of business requirements for departmental requests including regulatory reporting.
• Monitors performance across programs to identify improvement opportunities, leverage best practice and knowledge sharing for the purpose of improving outcomes through the standardization of evidence-based practices.
• Leads collaboration with all clinical teams and other stakeholders to ensure coordination and communication.
• Assists with the monitoring of legislative/governmental activities with the goal of coordinating the full integration of clinical services, identifying opportunities and issues.
• Supports the ongoing, data-driven approach to improve outcomes and experiences for members.
• Supports and leads readiness activities for implementation of new business and programs.
• Develops program documents and operational workflows.
• Engages stakeholders to ensure alignment across the organization.
• Adds services and processes related to the development of new lines of business as required.
• Recruits, develops, and leads key staff.
• Perform any other job-related instructions, as requested.

Skills

Visio

Microsoft Word

Microsoft Excel

PowerPoint

Project

Communication skills

Teamwork

Independent work

Organizational skills

Time management

Analysis

Problem solving

Project management

Leadership

Training

Strategy

Health Services Knowledge

Education

Bachelor’s Degree or equivalent years of relevant work experience

Master’s degree in Health Care Administration

Job description

Job Summary:

The Director, Utilization Management Operations assists the UM Department with all open projects and progress towards company and department initiatives including program descriptions, evaluations, policies, procedures, new business requirements, contract compliance and execution, and all related activities

Essential Functions:

• Manages and prioritizes UM and related projects, and ensures timeliness and adherence to completion
• Responsible for gathering and prioritization of business requirements for departmental requests including regulatory reporting
• Monitors performance across programs to identify improvement opportunities, leverage best practice and knowledge sharing for the purpose of improving outcomes through the standardization of evidence-based practices
• Leads collaboration with all clinical teams and other stakeholders to ensure coordination and communication
• Assists with the monitoring of legislative/governmental activities with the goal of coordinating the full integration of clinical services, identifying opportunities and issues
• Supports the ongoing, data-driven approach to improve outcomes and experiences for members
• Supports and leads readiness activities for implementation of new business and programs
• Develops program documents and operational workflows
• Engages stakeholders to ensure alignment across the organization
• Adds services and processes related to the development of new lines of business as required
• Recruits, develops, and leads key staff
• Perform any other job-related instructions, as requested

Education and Experience:

• Bachelor’s Degree or equivalent years of relevant work experience is required
• Master’s degree in Health Care Administration and two years of post‑degree professional experience is preferred
• Minimum of five (5) years medical management operations, leadership, program, or management experience is required
• Minimum of one (1) year Utilization Management experience preferred
• Experience implementing programs with focus on integration is preferred
• Experience with Medicaid, Medicare, Commercial and Managed Care is preferred

Competencies, Knowledge and Skills:

• Strong Knowledge of Visio, Microsoft Word, Excel, PowerPoint and Project
• Strong communication Skills; written and verbal
• Ability to work independently and within a team environment
• Strong organizational, time management, analysis, and problem solving skills
• Ability to manage a project from start to finish
• Strong relationship building skills and leadership qualities
• Training and teaching skills/change agent
• Ability to think critically and lead with strategy
• Comprehensive knowledge base crossing all areas within the Health Services Areas including: Behavioral Health, Case Management, Utilization Management, Integration and Pharmacy

Licensure and Certification:

• Current, unrestricted RN licensure is preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Some travel may be required to fulfill the duties of the role

Compensation Range:

$135,600.00 - $237,400.00

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Salary

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.