The Director, Utilization Management is responsible for the direct supervision of the Utilization Review Nursing Staff to include onsite and telephonic review, discharge planning activities and case management. This director is also responsible for 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. Additionally, this Director will 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.
Qualifications: * Registered Nurse, BSN. * MBA , MPH and MSN preferred * Three years' experience in Utilization Management in a managed care environment required. * Certification in Managed care or Utilization Management required or must receive within 18 months of employment. * Five years supervisory experience of professional staff required.
Other Skills: * Microsoft Office, MS Excel. * Strong analytical and research skills.
The Harris Health System is a fully integrated healthcare system that cares for all residents of Harris County, Texas. We are the first accredited healthcare institution in Harris County to be designated by the National Committee for Quality Assurance as a Patient-Centered Medical Home, and are one of the largest systems in the country to achieve the quality standard. Our system includes 23 community health centers, five school-based clinics, a dental center and dialysis center, mobile health units, a rehabilitation and specialty hospital and two full-service hospitals.Ben Taub Hospital is a world renowned Level I Trauma Center with 586 licensed acute-care beds and provides a wide range of specialty care outpatient services. Lyndon B. Johnson Hospital is a 328 licensed bed acute-care hospital with a newly expanded Level III trauma center and a distinguished regional center for neonatal intensive care for high-risk deliveries.Harris Health is a teaching system for Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth). We train the next generation of healthcare providers on the latest medical procedures and technological breakthroughs.With... our fully integrated electronic medical records system, we offer patients the convenience and assurance that their medical history is accurate, safe and available when and where it is needed. Our Medical Home designation ensures that we offer a full range of preventive, specialty and acute care services for the entire family.