Director, Utilization Management

Job Number: 7214

Workplace Type: Hybrid Remote

Position Title: Director, Utilization Management

External Description:

Position Summary:

This job is responsible for the provision of leadership, direction, oversight, and operations management for the Organization's Utilization Management (UM) functions across all markets for AHP. The incumbent interprets key performance metrics to develop plans, mobilize the work force, and achieve the Organization's UM outcomes relative to the Triple Aim (improved population health, improved experience of care, and lower healthcare costs). Accountable for the strategic and operational excellence of the UM function within Clinical Services including administrative and care cost initiatives, system development and delivery of high-quality outcomes, compliance with all state and federal regulations that affect UM activities and executive level reporting, and communication as needed. 

This position builds and maintains strong collaborative partnerships with key partners in the Clinical Services organization including Care Management, Performance Improvement, Medical Management and Policy including Quality and Medical Review and Appeals, Pharmacy, and Provider Integration to identify, develop, implement, and monitor performance metrics related to UM Operations. 

This position also builds strong collaborative partnerships internally and externally with key stakeholders and vendors to ensure that internal and external UM operations programs are well-coordinated and work cooperatively to achieve outcomes goals. Areas of direct responsibility include Medical Utilization Management including Inpatient Review & Prior Authorization, SNF concurrent review, and pre-service authorization process. 

General Duties/Responsibilities (May include but are not limited to):

· Perform management responsibilities to include but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. 

· Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement workflows as necessary.  

· Participate in strategic planning and in the establishment of strategic directions and goals for all clinical services operations. 

· Participate in the establishment, monitoring, and reporting of key metrics to manage performance related to clinical services processes and functions. 

· Build alliances across the business and clinical leadership teams with the end objective of a collaborative, efficient and viable operating model.  

· Innovate and implement new or revised models for the Organization's UM operations functions in response to evolving trends in healthcare delivery and/or emerging models of care.  

· Serve as a change agent, assisting others in understanding the importance, necessity, impact and process of change through active involvement in decision making and coaching of leaders and staff. 

· Utilize proven performance improvement methodologies and incorporates a strong emphasis on data to drive the implementation of improvements in the Organization’s UM operations and organizational culture in order to achieve improved outcomes metrics relative to the Triple Aim (improved population health, improved experience of care, and lower healthcare costs).  

· Accountable for maintaining updated, current competencies, knowledge and skills in healthcare management trends, legal/regulatory and accreditation standards, and payer-based best practices in medical management and for the application of such current concepts within the Organization’s clinical operations strategies, processes and functions. 

· Accountable for leadership and oversight of front-line UM operational organization including care manager LVN/RNs, Medical Review LVN/RNs, and non-clinical customer service reps.  

· Other duties as assigned or requested.

Supervisory Responsibilities:

Oversees assigned staff. Responsibilities include recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and performance improvement of employees.

Minimum Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Minimum Experience:

a. 5-6 years of experience in clinical services and/or health plan care management functions

b. Significant experience in case management, utilization management, and population health with solid knowledge of best practices in all aspects of medical management  

c. Proven ability to use medical management metrics and to develop data-based initiatives designed to improve outcomes relative to the Triple Aim  

d. Demonstrated ability to lead and motivate clinical and administrative groups to achieve specific objectives Preferred  

2. Education/Licensure:

a. LVN or RN active license is required

b. bachelor’s degree, Health/Clinical degree preferred (BSN, PA), or business related (Business, Health Administration) Preferred 

3.  Work Environment:

a. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Essential Physical Functions:

a. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

b. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Director, Utilization Management

Company Profile:

Alignment Health is revolutionizing health care for seniors by leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].