Director, Utilization Management
Corewell Health
Administration
Grand Rapids, MI, USA
Posted on Tuesday, August 6, 2024
Job Summary - Director, Utilization Management
The Director, Utilization Management is responsible for providing oversight to the utilization department in addition to coordinating projects in concert with other departments to meet overall project goals while maintaining expertise and oversight with compliance to regulatory and accrediting requirements that are applicable to Utilization Management and is responsible for reviewing and identifying and implanting processes to impact cost and utilization trends. Additionally, the Director will assume responsibility for all medical innovations projects and will plan, coordinate, and direct, from ideation to inception, all ideas and activities that may impact cost and care. The success of this position requires the ability to foster communication and teamwork to ensure an excellent customer experience.
Essential Functions - Director, Utilization Management
Oversees the development of the departmental strategic and tactical plans. Directs the development of Utilization Management goals, objectives, policies and priorities and promotes culture of compliance to policy and procedure. Participates in the development of new policies and procedures annual review of policies and procedures.
Develops and implements processes to ensure excellence in Utilization Management.
• Ensure that staff receive appropriate orientation, training and education.
• Leads the team to the fulfillment of the clinical, business and service level expectations of the organization.
• Provides oversight into the development, implementation and evaluation of departmental goals and objectives.Serves on applicable internal and external committees and actively participate in Departmental, Corporate and Network activities and projects that improve the departments performance and outcomes and assures the integration of Health Management activities within and between teams as well as across the entire Medical Department and the organization.
Maintains expertise in reimbursement methods and contract language related to Health Management activities(i.e.; DRGs, etc) and in all operational areas of the Health Management Department.
• Seeks and reviews new information as it becomes available.
• Ensures that the appropriate staff members are educated as needed.
• Ensures that documents, policies and procedures, and workflows are up to date as needed.Oversees all activities of Utilization area and collaborates with all business units as required.
• Ensures that the team confers with the Medical Directors for cases that do not meet criteria.
• Ensures that the established goal for turnaround times is monitored and takes action as needed, as well as all other compliance and SLA issues
• Ensures that processes are well-defined, documented and in accordance with regulatory and accrediting agencies.Participates in review, selection, upgrades and training of new technology for use in the Utilization Management area. In conjunction with Medical Operations and other leadership, identifies new or enhanced technology that will improve accuracy and efficiency. Oversees the development of a standard business case and ROI documents as needed.
Provides regulatory and accrediting oversight by reviewing changes in requirements and standards and identifies gaps and opportunity. Oversees the monitoring (in the form of quality assurance activities) and enforcement of compliance with internal and external regulatory and accrediting requirement.
• Identifies compliance issues.
• Participates in (or designates) development/revision of policies and procedures/workflows pertaining to compliance.
• Participates in (or designates) in staff education related to compliance.
Qualifications - Director, Utilization Management
Required Bachelor Degree or equivalent in health-related field
Preferred Master Degree or equivalent in health-related field
7 years of relevant experience Leadership Required
5 years of relevant experience Managed Care experience Preferred
5 years of relevant experience Knowledgeable of compliance and regulations as it relates to Utilization Preferred
#LI - CH
About Corewell Health
As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.
How Corewell Health cares for you
Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
On-demand pay program powered by Payactiv.
Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
Optional identity theft protection, home and auto insurance, pet insurance.
Traditional and Roth retirement options with service contribution and match savings
Physical Demands - Director, Utilization Management
Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs
Waist to Waist > 5 lbs: Seldom up to 10 lbs
Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
Waist to Overhead > 5 lbs: Seldom up to 10 lbs
Bilateral Carry > 5 lbs: Seldom up to 10 lbs
Unilateral Carry > 5 lbs: Seldom up to 10 lbs
Pushing Force > 5 lbs: Seldom up to 10 lbs
Pulling Force > 5 lbs: Seldom up to 10 lbs
Sitting: Frequently
Standing: Occasionally
Walking: Occasionally
Forward Bend - Standing: Seldom
Forward Bend - Sitting: Occasionally
Trunk Rotation - Standing: Seldom
Trunk Rotation - Sitting: Occasionally
Reach - Above Shoulder: Seldom
Reach - at Shoulder or Below: Seldom
Handling: Occasionally
Forceful Grip > 5 lbs: Seldom
Forceful Pinch > 2 lbs: Seldom
Finger/Hand Dexterity: Frequently
Primary Location
SITE - Priority Health - 1231 E Beltline - Grand RapidsDepartment Name
PH - Medical ManagementEmployment Type
Full timeShift
Day (United States of America)Weekly Scheduled Hours
40Hours of Work
8:00 a.m. - 5:00 p.m.Days Worked
Monday to FridayWeekend Frequency
N/ACURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.
Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.
Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.
An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.
You may request assistance in completing the application process by calling 616.486.7447.
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