Director - Utilization Management

CareCentrix - Remote2.7

Full-timeEstimated: $97,000 - $130,000 a year

As the Director of Utilization Management you will provide leadership and oversight of clinical and utilization management (UM) activities for programs in accordance with company policies and procedures. Works with the CareCentrix corporate UM department and the operations management team to develop, implement and manage effective UM initiatives designed to position CareCentrix as an industry leader for excellent clinical outcomes by obtaining optimal financial results for CareCentrix and their customers.

Supports and oversees Utilization Management activities to assure positive outcomes and that expectations are exceeded.
Assures that UM activities are compliant with regulatory and accreditation agency standards and client specific requirements.
Collaborates with Corporate UM department, Account Management, Clinical Management, Client Services and Health Plans in the development of clinical and UM program initiatives.
Work with CCX senior leadership Clinical Management to develop, direct and implement best practices for utilization and authorization management. Sets priorities and goals ensuring utilization performance, compliance and quality standards are met.
Assists with the development of reporting strategies and implements plans to ensure all outcomes are within stated objectives.
Ensures appropriate staff training for all new clinical initiatives and monitors outcomes/performance.
Collaborates with account management, client services and network management to provide education and training to referral sources and providers.
Directs and implements performance improvement activities to achieve desired goals when necessary. Ensures that information is documented/identified enabling the collection and root cause analysis of data to identify opportunities for improvement related to clinical programs.
Participates in educating associates, management, customers, payers and physicians in best practices and protocols of care that drive both excellent clinical performance as well as optimizing financial results.
Is the primary point of contact and responsible individual in internal and external audits of UM activities and outcomes.

Bachelor or Master’s degree in Healthcare field preferred
Active LPN/RN/LCSW or /LMHC licensure required with a minimum of 8 years of clinical experience
Experience with program development desired
Experience with data analysis and the design and use of clinical measurement systems
Excellent verbal/written communication and presentation
Wide-ranging knowledge and experience with utilization management and accrediting agency standards.

CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.

We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law.