Utilization Review Care Management Director

Intermountain Healthcare; United States; Remote; Full time

Job summary

A leading healthcare organization seeks a Utilization Review Care Management Director to oversee Utilization Management across the Enterprise. This role involves strategic leadership, collaboration with various teams, and ensuring compliance with healthcare regulations, ultimately aiming to enhance patient care and operational efficiency.

Benefits

Comprehensive benefits package

Annual Pay for Performance Plan

Qualifications

• Master’s degree required.
• 3 years in Utilization Management or 8 years in healthcare delivery.
• Professional nursing license required.

Responsibilities

• Lead partnerships with payors for Utilization Management.
• Collaborate with teams to improve patient care and reduce costs.
• Ensure compliance with NCQA standards.

Skills

Leadership

Communication

Strategic Planning

Negotiation

Education

Master’s Degree in Nursing or Healthcare Administration

Tools

Word Processing

Spreadsheets

Databases

Scheduling Tools

Job description

Job Description:

The Utilization Review Care Management Director is responsible for providing leadership and administrative direction for Utilization Management and Review across the Enterprise. The individual collaborates with Medical staff, Contracting, OPOE, Compliance, and Revenue Cycle leaders to ensure adherence to standards of practice, optimal patient care, and achievement of financial goals.

Reporting to the Sr. Director/AVP/VP of Utilization Management, the Director plays a crucial role in the success of our members and the UM department, focusing on delivering and collaborating on utilization management and care coordination in the Desert Region. The role involves providing leadership in compliance with regulatory requirements and operational metrics.

Responsibilities include:

1. Leading system-wide development of partnerships with payors to support Utilization Management.
2. Collaborating with Castell, Home Care, Clinic Management, and Operations teams to develop strategies and solutions to improve safety, quality, patient experience, access, and reduce care costs.
3. Leading NCQA Utilization Management Accreditation, survey processes, and annual standard reviews for compliance.
4. Developing growth opportunities in new states, establishing workflows for multimodal care management.

Minimum Qualifications:

• Master’s Degree in Nursing or Healthcare Administration from an accredited institution (education verified).
• At least three years of leadership experience in Utilization Management case management or eight years of progressive healthcare delivery experience.
• Professional nursing license (must be maintained).
• Knowledge of healthcare regulations, contractual requirements, and NCQA accreditation.
• Experience in contract negotiations and strategic planning, including proposal development, pilots, and project implementation.
• Proficiency in word processing, spreadsheets, databases, internet, email, and scheduling tools.
• Effective verbal, written, and interpersonal communication skills.

Preferred Qualifications:

• Experience in an integrated delivery system with a health plan.
• Experience directing clinical areas, working with physicians, and developing clinical strategies.
• Experience evaluating technology solutions for care management.
• Experience building collaborative relationships with payors across the healthcare continuum.

Physical Requirements:

• Verbal communication and hearing necessary for interaction.
• Ability to operate computers, phones, and office equipment, and manipulate paper.
• Visual acuity to read monitors and documents.
• Ability to sit or stand for extended periods.

This position is eligible for the Annual Pay for Performance (AP4P) Plan, offering additional performance-based compensation calculated as a percentage of the base salary, contingent on achieving approved goals.

Location: Intermountain Health St George Regional Hospital, Nevada Central Office

Work City: Las Vegas

Work State: Nevada

Scheduled Weekly Hours: 40

The hourly rate ranges from $66.41 to $102.52, depending on experience.

We offer a comprehensive benefits package supporting wellness and work-life balance. Learn more here.

Intermountain Health is an equal opportunity employer. We consider all qualified applicants regardless of race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

We use the AI platform HiredScore to enhance your application experience. All final hiring decisions are made by Intermountain personnel, ensuring fairness and privacy.

Positions are subject to closing without notice.