Strategic Director of Care Management & Appeals

Maine Community Health Options; Lewiston (ME); On-site; USD 133,000 - 154,000; Full time

Benefits offered by this job

Competitive cash compensation

Generous PTO

Future focused 401k match

Job summary

Maine Community Health Options is seeking a Director of Care Management, Utilization Management, and Appeals to guide care management programs, utilization processes, and appeals operations. This role requires strategic leadership to ensure high-quality, cost-effective care and regulatory compliance.

Under the guidance of the CMO, you will lead a team, manage budgets, and collaborate with senior leadership to align departmental goals with the organization’s mission and objectives, driving

Qualifications

• Bachelor’s degree in related health field, preferred.
• Minimum of 2-3 years of Health Plan Medical Management (Utilization Management and Appeals) experience.
• Leadership experience with working knowledge of human resource principles that promote a positive working environment and adherence to applicable regulatory requirements

Responsibilities

• Develop and implement strategic plans for care management, utilization management, and appeals programs.
• Lead and mentor a team of professionals in these areas, fostering a culture of excellence and continuous improvement.
• Collaborate with senior leadership to align departmental goals with the organization’s overall mission and objectives.
• Under the oversight of the CMO, manages budget for programs as well as care model
• Oversee care management programs to enhance member outcomes and satisfaction and reduce total costs of care.
• Monitor utilization data to identify trends and opportunities for cost savings and quality improvement.
• Oversee the appeals process to ensure timely and accurate handling of denials and appeals.
• Collaborate with clinical and operational teams to resolve complex cases and improve the appeals process.
• Oversight of Appeals Vendor contracts.
• Ensure all programs comply with federal, state, and local regulations and accreditation standards.

Skills

Leadership

Communication

Analytical skills

Problem solving

Education

Bachelor's degree in health-related field

Job description

Maine Community Health Options is seeking a Director of Care Management, Utilization Management, and Appeals to guide care management programs, utilization processes, and appeals operations. This role requires strategic leadership to ensure high-quality, cost-effective care and regulatory compliance.

Under the guidance of the CMO, you will lead a team, manage budgets, and collaborate with senior leadership to align departmental goals with the organization’s mission and objectives, driving