The Corporate Director of Clinical Utilization Management (UM) provides comprehensive oversight of the Utilization Review process for the self-insured Employee Health Plans, according to the EPO Plan Documents and any other applicable documents. Integrates and coordinates services using continuous quality improvement initiatives to promote positive member outcomes. Frequent executive level reporting and tracking on department and individual team productivity. The Corporate Director of Clinical UM assesses needs, plans, communicates, designs services and strategies to forward the mission and serve member needs. The Corporate Director provides strategic leadership, development, and supervision to utilization review department, provides interprofessional collaboration with facility-based case managers and discharge planners, and coordinates with all aspects of the Employee Health Plans Team, including Claims and Customer Service, to provide guidance on complex Authorizations, Referrals, Denials and Appeals. Integrates and coordinates services using continuous quality improvement initiatives to promote positive member outcomes.

Qualifications

Required qualifications:

Bachelor’s degree in Nursing, Healthcare Administration, or another relevant field

A minimum of seven (7) years’ experience in Clinical Utilization Review or Case Management with a large Health Plan

An active CA Registered Nurse license

Current BCLS (AHA) certificate upon hire and maintain current

Analytical ability for problem identification and assessment and evaluation of data/statistics obtained from an on-going review process.

Knowledge of Milliman Care Guidelines, InterQual Criteria, and CMS Criteria

Knowledge of self-funded health plans, ERISA and HIPAA guidelines

Experience and knowledge in intermediate computer skills (i.e. Microsoft Word, Excel)

Preferred qualifications:

Master’s Degree in Nursing, Healthcare Administration, or another relevant field

Professional Certification in Case Management

Claims experience, ideally with EPO Plan.