Director of Utilization Management - Health Plan

 
Position: Director of Utilization Management - Health Plan

Job ID: 154318

Location: US-TX-Bellaire

Department: UTILIZATION MGMT - ADMIN

Talent Area: Professional - Non-Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a-5p

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   To join our community of 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.   Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

Summary:

We are searching for a Director of Utilization Management -- someone who works well in a fast-paced setting. In this position, you will be responsible for responsible for planning, organization, and operation of the utilization management department. You will also be responsible for ensuring compliance with all regulatory responsibilities. Activities involve development of processes to optimize operations, supervision of development and updating of all policies & procedures, monitoring, and ensuring compliance with UMCC and TMPPM, and monitoring and ensuring compliance with TDI. You will also work in coordination with the Medical Director of Utilization Management to ensure appropriate analysis and implementation of medical policy.

Think you’ve got what it takes?



Responsibilities :

  • Provides leadership in the development, direction, execution, and evaluation of an effective utilization management program that supports the delivery of quality healthcare
  • Works with the CMO to develop medical review criteria for utilization of medical and behavioral health services
  • Oversees the clinical professional review of medical and/or behavioral health care by registered nurses and ensures regulatory compliance and compliance with accreditation agencies
  • Coordinates training of utilization management staff to ensure a comprehensive, up-to-date knowledge base for medical and behavioral health reviews
  • Partners intentionally and strategically with utilization management leadership across the organization, leveraging data to drive decision making, to ensure consistent execution of utilization management vision across entities
  • Completes timely performance appraisals for direct reports
  • Submits performance planning documents, ongoing planning materials, action plan and departmental goals


Qualifications:

  • Bachelor’s degree in nursing required
  • Master’s degree in nursing, business or healthcare required
  • RN license from the Texas Board of Nursing required
  • 5 years’ healthcare management or managed care experience required


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