Director, Utilization Management

Lead and manage all functions within medical management and level one case management programs to ensure consistent, efficient delivery of services throughout the healthcare continuum and demonstration of positive outcomes
Leadership role in transitioning to the “next generation” of Care Management
Continuous review of business workflows to improve productivity and ensure member and provider satisfaction
Facilitate and promote problem identification, analysis and resolution
Expand ability to meet State contract requirements with proactive processes to ensure success
Ensure monitoring of regulatory requirements and oversight of all submissions
Determine benchmarks, goals and outcomes for all programs as well as high cost, volume and risk conditions
Determine benchmarks, goals and outcomes for staff and implement an accountability system
Monitor CQI activities in accordance with regulatory requirements and URAC standards
Develop and coach employees
Build succession plan for Director and Manager positions
Foster relationships with hospitals, physicians and community agencies
Identify “wellness continuum” opportunities and develop successful blending of case, disease and medical management functions
Identify and report risk management issues for the department and CareSource as a whole
Perform any other job related instructions, as requested

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