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Community Health Options · 3 weeks ago

Director of Care Management, Utilization Management & Appeals

United States

Full-time

Remote

Mid Level

2+ years exp

Community Health Options is seeking a Director of Care Management, Utilization Management, and Appeals to oversee and enhance their care management programs. The role involves strategic leadership and ensuring high-quality, cost-effective care while complying with regulatory requirements.

Health CareInsuranceNon Profit

Responsibilities

Develop and implement strategic plans for care management, utilization management, and appeals programs

Lead and mentor a team of professionals in these areas, fostering a culture of excellence and continuous improvement

Collaborate with senior leadership to align departmental goals with the organization’s overall mission and objectives

Under the oversight of the CMO, manages budget for programs as well as care model

Oversee the development and execution of care management programs to enhance member outcomes and satisfaction and reduce total costs of care

Ensure that effective care management is integrated into CHOs population health strategy

Monitor and evaluate care management performance metrics and implement strategies for improvement

Manage utilization review processes to ensure appropriate use of resources and adherence to clinical guidelines

Develop policies and procedures for utilization management that comply with regulatory standards and payer requirements

Analyze utilization data to identify trends and opportunities for cost savings and quality improvement

Oversight of the appeals process to ensure timely and accurate handling of denials and appeals

Develop and maintain policies and procedures for appeals management, ensuring compliance with regulatory and contractual requirements

Collaborate with clinical and operational teams to resolve complex cases and improve the appeals process

Oversight of Appeals Vendor contracts

Ensure all programs comply with federal, state, and local regulations, as well as accreditation standards

Implement quality improvement initiatives to enhance the effectiveness and efficiency of care management, utilization management, and appeals processes

Stay abreast of industry trends and best practices to maintain a competitive edge

Work closely with internal and external stakeholders, including healthcare providers, payers, and regulatory agencies, to optimize care delivery and resource utilization

Foster strong communication and collaboration among multidisciplinary teams to support integrated care management and utilization management efforts

Qualification

Health Plan Medical ManagementUtilization ManagementAppeals ManagementRegulatory ComplianceLeadership ExperienceAnalytical SkillsMicrosoft ProductsClinical LicenseCommunication SkillsProblem-Solving Skills

Required

Active and unrestricted Maine (or contract state) clinical license

Minimum of 2-3 years of Health Plan Medical Management (Utilization Management and Appeals) experience

Leadership experience with working knowledge of human resource principles that promote a positive working environment and adherence to applicable regulatory requirements