This job is responsible for the provision of leadership, direction, oversight, and operations management for the Organization's Utilization Management (UM) functions across all lines of business including commercial and government programs. The incumbent interprets key performance metrics to develop plans, mobilize the work force, and achieve the Organization's UM outcomes relative to the Triple Aim (improved population health, improved experience of care, and lower healthcare costs). Accountable for the strategic and operational excellence of the UM function within Clinical Services including administrative and care cost initiatives, system development and delivery of high quality outcomes, compliance with all state and federal regulations that affect UM activities and executive level reporting and communication as needed. This position builds and maintains strong collaborative partnerships with key partners in the Clinical Services organization including Care Management, Performance Improvement, Medical Management and Policy including Quality and Medical Review and Appeals, Pharmacy, and Provider Integration to identify, develop, implement, and monitor performance metrics related to UM Operations. This position also builds strong collaborative partnerships internally and externally with key stakeholders and vendors to ensure that internal and external UM operations programs are well-coordinated and work cooperatively to achieve outcomes goals. This position will also work closely with providers such as AHN, strategic partners, etc. to maximize outcomes. Areas of direct responsibility include Medical Utilization Management including Inpatient Review & Prior Authorization, Pharmacy Utilization and Behavioral Health.
- Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
- Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
- Participate in strategic planning and in the establishment of strategic directions and goals for all clinical services operations.
- Participate in the establishment, monitoring, and reporting of key metrics to manage performance related to clinical services processes and functions.
- Accountable for achieving established outcomes goals relative to UM operations.
- Build alliances across the business and clinical leadership teams with the end objective of a collaborative, efficient and viable operating model.
- Innovate and implement new or revised models for the Organization's UM operations functions in response to evolving trends in healthcare delivery and/or emerging models of care.
- Serve as a change agent, assisting others in understanding the importance, necessity, impact and process of change through active involvement in decision making and coaching of leaders and staff.
- Utilize proven performance improvement methodologies and incorporates a strong emphasis on data to drive the implementation of improvements in the Organization’s UM operations and organizational culture in order to achieve improved outcomes metrics relative to the Triple Aim(improved population health, improved experience of care, and lower healthcare costs).
- Accountable for maintaining updated, current competencies, knowledge and skills in healthcare management trends, legal/regulatory and accreditation standards, and payer-based best practices in medical management and for the application of such current concepts within the Organization’s clinical operations strategies, processes and functions.
- Accountable for leadership and oversight of front line UM operational organization including care manager RNs, Medical Review RNs, Behavioral Health Specialists and non-clinical customer service reps.
- Other duties as assigned or requested.
- Bachelor's Degree, Health/Clinical degree preferred (BSN, PA), or business related (Business, Health Administration)
- Master’s Degree in Business, Healthcare Policy, Health Administration, Economics, or related field or equivalency demonstrated through a combination of years of experience and proven skills
- 10-12 years of experience in clinical services and/or health plan care management functions with at least 5 years of experience in a senior leadership position
- Significant experience in case management, utilization management, and population health with solid knowledge of best practices in all aspects of medical management
- Proven ability to use medical management metrics and to develop data-based initiatives designed to improve outcomes relative to the Triple Aim
- Demonstrated ability to lead and motivate clinical and administrative groups to achieve specific objectives
- 10-12 years of experience in clinical services and/or health plan care management functions with at least 5 years of experience at the executive or director level
- Clinical leadership experience in multiple settings of care (e.g. ambulatory, acute and post-acute care)
- Clinical leadership experience in both the provider setting and in health plan or payer settings
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org