Director Utilization Management

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Exemption Status:

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This position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process.

Everyone Is a Caregiver

At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 16,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day.

I.     Major Responsibilities:

1.    Designs work processes and assignments of utilization management staff, including level of care assignment and denials prevention, and supports staff in a manner that promotes care management performance that optimizes clinical and financial outcomes, and patient and staff satisfaction.
2.    Identifies objectives and creates performance goals upon which to evaluate the performance of utilization management staff and of the program.
3.    Integrates innovative technology into the utilization management process to improve programmatic effectiveness and enhance staff satisfaction and clinical outcomes for patients.
4.    Promotes integration of clinical guidelines, performance improvement initiatives, and patient satisfaction efforts into the utilization management program.
5.    Ensures that the utilization management functions comply with regulatory and reporting requirements and maintains awareness of changing requirements.
6.    Develop and maintain good relationships with Physician Advisors, care coordination, clinical denials, and care teams.
7.    Assures that utilization management operations are integrated with internal revenue cycle systems and third-party payer systems as appropriate.

II.     Position Qualifications:
License/Certification/Education:
Required:
1.    Bachelor’s degree in nursing, healthcare, program management, MBA, finance, social work, public health, or another related field.
2.    Current Massachusetts RN license and registration.

Preferred:
1.    Master’s degree in nursing, healthcare, program management, MBA, finance, social work, public health, or another related field.
2.    Certified Case Manager (CCM)
3.    Certified Professional in Healthcare Quality (CPHQ)
4.    Certified Utilization Review Specialist (CURS)

Experience/Skill:
Required:
1.    Five years managing teams or projects in a healthcare environment.
2.    Five years of Case/Utilization Management experience.
3.    Five years of conducting and managing Utilization Reviews using InterQual Criteria.
4.    Five years of creating and managing workflows and processes and developing and managing departmental budgets experience.
5.    Five years of analyzing healthcare utilization data, implementing metrics, and ensuring efficiency.
6.    Five years of operating in a union environment.
7.    Five years of planning, organizing, and evaluating programs.
8.    Five years of developing policy, including cross-functional collaboration.
9.    Five years of presenting utilization data to executive leadership. This is to include reporting on metrics and solutions to address gaps.
10.    Proficiency in common computer applications like Microsoft Word, Excel, PowerPoint, Outlook, and the ability to navigate basic computer functions like email, file management, and internet browsing.
11.    Demonstrated excellence in written and oral communication, with the ability to convey complex information clearly and effectively to diverse audiences.

Preferred:
12.    Five years of experience in a clinical setting, such as nursing, case management, or social work.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

We’re striving to make respect a part of everything we do at UMass Memorial Health – for our patients, our community and each other. Our six Standards of Respect are: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player and Be Kind. If you share these Standards of Respect, we hope you will join our team and help us make respect our standard for everyone, every day.

As an equal opportunity and affirmative action employer, UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives and backgrounds. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, gender identity and expression, protected veteran status or other status protected by law.

If you are unable to submit an application because of incompatible assistive technology or a disability, please contact us at talentacquisition@umassmemorial.org. We will make every effort to respond to your request for disability assistance as soon as possible.