Director, Utilization Management

Company: Santa Clara Family Health Plan
Location: San Jose
Posted on: March 24, 2025

Job Description:

Director, Utilization Management Salary Range: $171,721 - $274,753
The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.FLSA Status: ExemptDepartment: Health ServicesReports To: Vice President, Health Services GENERAL DESCRIPTION OF POSITIONThe Director of Utilization Management (UM) is responsible for the clinical and operational management of the Utilization Management Department activities including utilization management, concurrent review, prior authorization, care coordination, discharge planning, retrospective review, and claims support, including staff management to ensure that all administrative utilization management (UM) processes are performed in accordance with applicable state and federal regulatory requirements, SCFHP policies and procedures and business requirements. ESSENTIAL DUTIES AND RESPONSIBILITIESTo perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily.

• Manage and perform utilization management activates to ensure regulations, compliance, criteria, standards, and metrics as established by the Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), and Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and Healthcare Effectiveness Data and Information set (HEDIS) for Medi-Cal and Medicare lines of business.
• Responsible for the development, design, implementation, and evaluation of the strategic plan for the UM department including the UM program, work plan, evaluation, and oversight of delegated UM functions.
• Maintain accountability for utilization management functions to achieve business and clinical outcomes, meeting contract requirements, and supporting cross departmental initiatives with providers and members.
• Manage effectiveness of UM coordinators and nurse's review, coordination, and processing of prior authorization, concurrent review, discharge planning, and transitions of care activities including appeals, claims, provider disputes in accordance with established policy and standardized guidelines.
• Monitor and evaluation of under-/over utilization medical services and durable medical equipment for health outcomes analysis including but not limited to identifying gaps in care, cost effectiveness, vendor administration, and quality improvement opportunities through claims, encounter data, and prior authorization data.
• Produce and submit regular reports and data analytics as required for, but not limited to, all medical services, compliance dashboard, regulatory requirements, productivity, clinical operations, benefit changes, implementation, and service quality monitoring.
• Direct and participates in various meetings including the Utilization Management Committee, UM delegation oversight meetings, and additional interface with providers, delegates, vendors, hospitals, skilled nursing facilities, and community partners.
• Assist Health Services Leadership and Medical Directors with activities to meet departmental and organization objectives and implementing action plans to address issues and improve key performance indicators and selected utilization/cost and quality outcomes.
• Work cross functionally across departments to ensure timely implementation of benefit changes, regulatory requirements, and member and provider satisfaction.
• Responsible for overseeing and maintaining UM contracts and Letter of Agreements (LOA).
• Develop, coordinate and approve all departmental budget for the UM department. Assist with education of managers on the budget process and ensure appropriate monitoring of these areas is actionable.
• Perform all job functions with integrity. Provide timely internal and external customer service in cooperative, professional, and respectful manner.
• Responsible for staffing ratios and projecting changes in staffing with new programs and member ratios.
• Assist with system-wide initiatives as it relates to utilization of medical services and coordination of medical care including UM software/application implementations.
• Attend off-site meetings or events as necessary.
• Perform other related duties as required or assigned. SUPERVISORY/MANAGEMENT RESPONSBILITIES
• Carries out supervisory/management responsibilities in accordance with the organization's policies, procedures, applicable regulations and laws. Responsibilities include:
• Recruiting, interviewing, and hiring.
• Developing a high performing department culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives.
• Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance.
• Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees' needs, ensuring they have the necessary resources to do their work.
• Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews. REQUIREMENTS - Required (R) Desired (D)
• Current unrestricted California Registered Nurse (RN) license or qualified health care professional. (R)
• Bachelor's Degree from an accredited four-year institution. (R)
• Master's Degree in Nursing or related field. (D)
• Minimum five years of experience in Managed Care, Utilization Management, Quality Improvement, or equivalent. (R)
• Minimum five years of experience in a supervisory capacity in a managed care setting. (R)
• Comprehensive understanding of applicable standards and regulations pertaining to utilization management programs for DHCS, DHMC, NCQA, CMS and NCQA. (R)
• Knowledge of medical cording practices. (R)
• Knowledge of MCG guidelines, InterQual criteria, Medi-Cal Provider Manual, or CMS Guidelines. (R)
• Current working knowledge of Medicare and Medi-Cal rules and regulations. (R)
• Ability to consistently meet accuracy and timeline requirements to maintain regulatory requirements (R)
• Familiarity with Health Maintenance Organization (HMO), Independent Practice Association (IPA), and medical group contracting concepts, principles and practices. (D)
• Strong attention to detail and able to concentrate without distraction in a fast paced environment. Able to adapt to a rapidly changing environment and to keep supervisor informed of any delays which could disrupt delivery of health care services or the internal operations. (R)
• Self-directed with proven ability to work independently under general direction and minimal supervision; able to assume responsibility, take initiative, follow up on assignments, make appropriate decisions within the scope of the position, handle multiple projects simultaneously and assume accountability for own errors. (R)
• Strong working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs. (R)
• Ability to use a keyboard with moderate speed and high level of accuracy. (R)
• Excellent written, verbal, and interpersonal communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing. (R)
• Ability to comply with all SCFHP policies and procedures. (R)
• Ability to think and work under pressure and effectively prioritize and complete tasks within established timeframes. (R)
• Ability to assume responsibility and exercise sound judgment when making decisions within the scope of this position. (R)
• Maintenance of a valid California Driver's License and acceptable driving record in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R)
• Ability to perform the job safely and with respect to others, to property and to individual safety. (R) PHYSICAL REQUIREMENTSIncumbents must be able to perform the essential functions of this job, with or without reasonable accommodation.
• Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies; and sit or stand for extended periods of time. (R)
• Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds. (R)
• Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less. (R)
• Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment. (R)
• Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone. (R)
• Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person, by telephone, and electronically throughout a typical workday; attention to detail. (R)ENVIRONMENTAL CONDITIONSGeneral office conditions. May be exposed to moderate noise levels.EOERequired

Keywords: Santa Clara Family Health Plan, San Jose , Director, Utilization Management, Executive , San Jose, California