Job DescriptionThe Regional Director, Utilization Management (UM) directs, coordinates and oversees utilization management activities for multiple markets within Magellan Complete Care. In partnership with national UM leadership, this position provides the vision and strategy for inpatient/outpatient utilization and prior authorization management activities designed to achieve business, clinical and quality outcomes, meeting contract requirements, accreditation standards, and supporting initiatives with providers and members to manage cost of care. The Regional Director develops and works through others to execute strategy to meet objectives including utilization targets, financial objectives, quality improvement and employee satisfaction.
- Directs, coordinates and evaluates efficiency and productivity of utilization management functions for inpatient care, discharge planning and authorization services. Ensures monitoring and tracking tools are in place to adequately link and assess production and quality driven work and outcomes to individual performance.
- Serves as subject matter expert for inpatient and prior authorization management for future expansion and growth efforts.
- Works closely with pharmacy and vendors to assure integration, oversight and efficiency of UM and appeals processes and for delegated functions.
- Develops processes and procedures to ensure compliance with contractual, regulatory and accreditation activities.
- Leads and organizes the ongoing evaluation of the utilization management program against quality and utilization benchmarks and targets.
- Identifies opportunities for improvement; organizes and manages cost of care initiatives.
- Collaborates with local and national leaders including Quality Improvement, Analytics, Finance, Network, and other areas to assure a comprehensive approach to managing quality of care, service, and cost of care.
- Provides expert input to Finance regarding patterns of utilization and cost and high cost cases.
- Manages, selects, leads and develops high performing teams, promoting a culture of high employee satisfaction.
- Collaborates with Network leaders to design and operationalize successful methods for working with hospitals, home health, and other services.
- Assures integration and efficiency of Network strategy and vendor relationships with utilization management and claims processes.
- Works closely with network on the training and evaluation of providers as well in resolving provider related issues.
- Develops staffing models and manages staffing ratios of all UM staff, the assignment of duties, the supervision of the effectiveness of the UM program related to staff, within the structure of the budget for the department
- Responsible for resolution and communication of utilization management issues and concerns and corrective action plan activities and reporting.
General Job Information
TitleRegional Director, Utilization Management, Magellan Complete Care
Job FamilyClinical Services Group
CountryUnited States of America
FLSA StatusUnited States of America (Exempt)
Recruiting Start Date1/29/2020
Date Requisition Created1/28/2020
Work ExperienceClinical, Management/Leadership, Medicaid, Medicare, Utilization Management
EducationBachelors: Nursing (Required)
License and Certifications - RequiredRN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt
License and Certifications - Preferred
Other Job Requirements
- Bachelor degree in Nursing
- RN license
- 7+ years of experience in utilization management operations and familiarity with reporting and analyzing managed care utilization data.
- 7+ years of managed care experience, including Medicaid and Medicare clinical experience.
- Must have proven success in managing large teams across multiple markets with staff in multiple geographic regions.
- Must have experience overseeing contractual performance standards.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.
“I receive a high level of support from our Senior Management Team to execute on our vision. They are always accessible and approachable, something I’ve found to be very unique to Magellan.”