Director, Utilization and Medical Expense Review

What We Provide

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

What You Will Do

• Directs and oversees day to day operations of utilization management (UM) for Inpatient, Outpatient, Prior authorization and rehab/skilled services for members in VNS Health Plans products.
• Leads and directs the overall operation of the utilization management function to ensure consistency of policies, procedures, and workflows. Monitors compliance and administration of utilization policies in accordance with State and Federal regulations.
• Assists management to ensure that strategic plans, goals, and financial targets are implemented within each business unit to support the growth and fiscal solvency of the plan
• Evaluates Utilization Management (UM) program effectiveness and recommend improvements, including needs analysis and planning
• Develops and implements robust performance and operational metrics for all processes and products to include outcome metrics for specific products * Ensures any delegated services for UM are completed within expected timeframe and supports delegated vendor team quality audits.
• Evaluates effectiveness of clinical operations utilizing MCG, LCD, NCD and medical policies/utilization policies to ensure appropriate and timely determinations for UM staff. Supports quality of care using benchmark and objective data, including but not limited to, member health outcomes, satisfaction survey results (CAHPS), utilization metrics, and HEDIS star ratings.
• Ensures clinical criteria and guidelines are implemented consistent with evidenced based protocols. Ensures that all activities for VNS Health Plans operations are in compliance with federal, state and local health care regulations and standards of accrediting organizations; oversees the periodic review and audit to ensure compliance with program policies, state and federal regulations.
• Writes policies and procedures consistent with current processes and compliant with Federal and NYS regulations. * Collaborates with VNS Health Plans senior leadership to ensure budgetary compliance.
• Ensures infrastructure efficiencies that enable the delivery of operationally excellent, high quality services.
• Directs, develops and maintains medical management processes including program development, enhancements and evaluation of services across continuum of healthcare needs and settings.
• Collaborates internally to coordinate appropriate utilization to meet member needs. Co-chairs UM/CM committee and attends QIC committee meetings
• Oversees multi system integrity, upgrades, customization and reporting to ensure departmental efficiencies and regulatory compliance.
• Participates in the development and implementation of long-range strategic plans, goals and objectives. Ensures that strategic plans, goals and financial targets are implemented within the business units to support the growth and profitability of the plan.
• Performs all duties inherent in a managerial role. Ensures effective staff training/cross training, evaluates staff performance, and approves hiring, promotions, salary actions and terminations. Recommends and monitors productivity and staffing ratios to achieve administrative cost ratio targets.
• Participates in special projects and performs other duties as assigned.

Education:
Bachelor's Degree in Nursing required. Master's Degree in Nursing plus a graduate or doctoral degree in a healthcare related field preferred

Work Experience:
Minimum eight years Utilization Management / Quality Improvement experience in a managed care/HMO organization required. Minimum five years managerial experience over a managed care medical management system required. Experience with State and external accreditation managed care audits and reviews required. Experience with Health Plan Employer Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and Health Outcome Surveys (HOS) required. Experience with Quality Assessment and Process Improvement (QAPI) projects required. Experience with writing and implementing program level policy and procedures required