The Director, Utilization Management is reponsible for direct supervision of Utilization Review nursing staff: Onsite and telephonic review including discharge planning activities and case management to include tracking and trending inpatient and outpatient utilization, provider corrective action for utilization trends that have variances and reporting the UM statistical data to the Medical Director. Direct supervision of the Retrospective review and Appeals team: including tracking and trending types of retrospective reviews and appeals, overturns, fair hearing and IRO results and assuring turnaround times are met. Responsibilities also include compliance with THHSC regulations for conveying adverse determinations decisions to Community Health Choice (Community) providers and members and ensuring all communications to providers and members adhere to HIPPA and THHSC regulations. Ensures compliance with THHSC, TDI, NCQA, URAC and any other regulatory body involved in policies and procedures related to Utilization Management. Review, monitor and report KMR activities to staff, Senior Vice President of Medical Affairs, and Community Management. Liaison for Medical Affairs with Community Directors to improve efficiency of processes. Respond to all UM deficiencies by regulatory agency audits.
BSN degree, active Texas RN license.
Certifications in Managed Care, or Utilization Management required or must receive within 18 months of employment.
Master of Business Administration (MBA), Master of Public Health (MPH), Master of Health Administration (MHA) and/or Master of Science in Nursing (MSN) preferred
Three years’ experience in Utilization Management in a Management Care environment required.
Five years supervisory experience of Managers or above required
Experience with working with applicable state, federal and third party regulatory agencies such as, CMS, HHSC, TDI, Medicaid or Medicare programs required.
In addition to a highly competitive salary with day-1 benefits, Community Health Choice offers:
401(k) with company match up to 5% and employee catch up contributions up to 75%
Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers. Equal opportunity employer.