UM Clinical Assistant Vice President

Beacon Health Options - Cypress, CA (30+ days ago)3.2

We are currently seeking a dynamic Assistant Vice President (AVP) of Utilization Management to join our team in Cypress,CA! The AVP of Utilization Management is responsible for the direction and leadership of a performance driven utilization management program including the on-going monitoring of operational performance and workforce management, focus on continuous performance improvement, and the monitoring of utilization data and trends in the assigned region. This position will have oversight of the operational non- clinical and clinical teams ensuring all systems are in place to meet regulatory, client and clinical best practices. Regional AVP of Utilization Management assist with market and/or provider strategy initiatives.

Position Responsibilities:

The Regional AVP of UM is responsible for ensuring the region meets all UM performance and productivity targets. Responsibilities include:
  • Continuously monitor utilization management productivity and other operational metrics for region; identify issues related to changes in productivity; direct and oversee appropriate interventions to manage productivity to targets
  • Supervise and oversee Utilization Management Directors in the day-to-day operations of the UM department
  • Work with the VP of Utilization Management to identify necessary changes in UM algorithms to ensure appropriate authorizations are being automated; oversee
  • algorithm adjustments and the operational processes to ensure their accuracy
  • Continuously monitor processes and procedures and develop recommendations to create efficiencies; direct and oversee recommended changes to processes and
  • systems
  • Ensure corporate policies are followed and local policies and processes are developed to support operations of regional units
  • Maintain a pro-active quality and process improvement program with in line with corporate policies, procedures and protocols, auditing mechanisms and data
  • reporting systems
  • Assist in recruitment, training and evaluation of key UM management

The Regional AVP of UM is responsible for ensuring that the operations of the regional UM team are aligned to support the regions MLR and clinical quality targets. Responsibilities include:
  • Provides oversight and direction in the development and implementation of initiatives related to utilization management and associated medical expense
  • Monitor, analyze, and report on trending of utilization data, working with the Regional VP of UM, Chief Operating Officer (RCOO), Regional Clinical and Quality Lead (RCQL),
  • Regional Chief Financial Officer (RCFO) to recommend targets; to
  • assess performance against established targets; and to facilitate effective interventions where variance from UM targets may be identified locally or regionally
  • Collaborate with Corporate Quality to understand, implement, and continuously monitor regional and company-wide quality initiatives
  • Participate in regional operations and/or finance meetings where MLR and other operational initiatives are discussed that impact UM
  • Collaborate with the RCQL to develop and implement processes to support effective handoffs to case management and aftercare teams
  • Collaborate with the RCQL and RCOO to develop provider quality strategies and/or enhancements and changes to UM operations (i.e., algorithm changes, etc.)
  • Works closely with regional medical directors and UM Shared Services Appeals and Denials team to ensure compliance with all internal and external standards and
  • understand regional trends

The Regional AVP of UM is responsible for ensuring that the region’s UM activities meet regulatory compliance requirements and client demands. Responsibilities include:
  • Develop and direct appropriate workforce management protocols, as appropriate and based on client and regulatory direction
  • Collaborate on the regional quality committee structure, processes and quality documentation to be in compliance with Client enterprise and customer requirements
  • including: preparation of annual documents, development and monitoring of core
  • performance indicators, obtainment of stakeholder input, processing of complaints and development of supportive tools and surveys.
  • Oversee UM portions of delegation agreements, customer audits and compliance activities
  • Act as a liaison in URAC and NCQA accreditation and certification activities with Beacon’s Quality Team including: continuous monitoring for standard compliance,
  • document retention and retention of certification and accreditation.
  • Collaborate with Legal on compliance activities for UM operations to ensure we are maintaining all contractual, legal and accreditation requirements
  • Participate in customer meetings as needed and development and implementation of new business, including contract reviews, proposal requests, sales presentations,
  • and RFP review

Position Requirements:
  • Education: Master’s Degree in mental health related field required
  • Licensure: Current, valid license required with proof on date of hire; re-verification will take place no less than every 3 years
  • Relevant Work Experience: 7 to 10 years combined direct behavioral health, supervisory and/or managed care experience required
  • Knowledge, Skills, & Abilities:
    • Senior-level experience with operations and UM; fluency in clinical operations and driving operational efficiencies while managing resulting impacts to MLR; and understanding of regulatory and accreditation requirements necessary.
    • Leadership skills and supervisory experience, including the ability to develop team performance
    • Excellent written and oral communication skills
    • Self-motivated, able to prioritize multiple issues, excellent organizational skills and attention to detail, ability to track multiple projects/tasks and follow through as needed
    • Ability to manage and coordinate with internal and external departments
    • Ability to manage staff in operations environment
    • Demonstrated leadership skills and experience, including the ability to work cross-functionally, build consensus and develop staff
    • Ability to manage time-sensitive projects and meet deadlines
    • Knowledge of CQI principles and ability to manage change
    • Ability to identify opportunities for improvements and recommend and implement innovative solutions
    • Able to work collaboratively with internal staff and external stakeholders (provider organizations, clients, etc.)
To Apply:

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Beacon Health Options is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled