Leads the oversight and management of key performance indicators and monitors and tracks to independently identify over/under utilization patterns and/or deviation from expected results. * Develops ...
Leads the oversight and management of key performance indicators and monitors and tracks to independently identify over/under utilization patterns and/or deviation from expected results. * Develops ...
SUMMARY The Utilization Management Specialist is responsible for coordinating and managing all ... Collaborates with program directors, treatment providers, and billing staff to resolve ...
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SUMMARY The Utilization Management Specialist is responsible for coordinating and managing all ... Collaborates with program directors, treatment providers, and billing staff to resolve ...
Provides leadership to Assistant Medical Director teams based upon specialty or geographic area and performs utilization management review in area of expertise. Fosters continuous improvement in ...
Provides leadership to Assistant Medical Director teams based upon specialty or geographic area and performs utilization management review in area of expertise. Fosters continuous improvement in ...
UM Director Job Post Title: Utilization Review Director Shift: M-F Hours: 8-4:30 9-5 The Role ... Manages patient transitions between LOC and updates denial log. * Develops processes to minimize ...
UM Director Job Post Title: Utilization Review Director Shift: M-F Hours: 8-4:30 9-5 The Role ... Manages patient transitions between LOC and updates denial log. * Develops processes to minimize ...
Utilization Management (UM) Coordinator
Blue Ash, OH · On-site
$27 - $34/hr
... Utilization Management (UM) Coordinator to join our team! Position Summary ... The UM Coordinator works with the Director of UM by providing the precertification and ...
Utilization Management (UM) Coordinator
Blue Ash, OH · On-site
$27 - $34/hr
... Utilization Management (UM) Coordinator to join our team! Position Summary ... The UM Coordinator works with the Director of UM by providing the precertification and ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
... direct admission processes. Combines clinical, business, and regulatory knowledge and skill to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...
Director Utilization Management information
What are the key skills and qualifications needed to thrive in the director utilization management position, and why are they important?
To thrive as a Director Utilization Management, you need a strong background in healthcare administration, case management, and data-driven decision-making, often supported by a clinical degree and several years of management experience. Familiarity with utilization management software, electronic health records (EHRs), and certifications such as CCM or ACM are typically valued. Exceptional leadership, communication, and problem-solving skills distinguish top performers in this role. These competencies are vital for optimizing resource use, ensuring regulatory compliance, and leading teams to meet quality care standards.
What is a director utilization management?
A Director of Utilization Management oversees the review and approval of medical services to ensure they are necessary, efficient, and cost-effective. They develop strategies to improve care quality while managing healthcare costs, working closely with providers, payers, and regulatory bodies. Their responsibilities include policy development, compliance with healthcare regulations, and leading a team of utilization review professionals. This role is common in hospitals, insurance companies, and managed care organizations.
What are the typical daily responsibilities of a director utilization management?
A Director Utilization Management generally oversees a team responsible for reviewing patient care to ensure appropriate resource use and compliance with payer requirements. Daily tasks may include analyzing utilization data, developing policy and process improvements, collaborating with clinical and administrative staff, and addressing escalated cases or issues. Directors frequently attend strategy meetings, conduct staff training, and engage with external partners like insurance providers. This role requires balancing administrative oversight with hands-on problem solving to support both cost efficiency and quality patient care.
What are the most commonly searched types of Utilization Management jobs in Ohio? The most popular types of Utilization Management jobs in Ohio are:
What are popular job titles related to Director Utilization Management jobs in Ohio? For Director Utilization Management jobs in Ohio, the most frequently searched job titles are:
- Director Of Nursing
- Remote Utilization Management
- Utilization Management Physician Reviewer
- Hospice Care Cna
- Cvs Health Utilization Management Remote
- Independent Contractor Remote Utilization Management Nurse
- Utilization Management Nurse Consultant
- Executive Director Healthcare
- Healthcare Revenue Cycle Manager
- Utilization Management Nurse
What job categories do people searching Director Utilization Management jobs in Ohio look for? The top searched job categories for Director Utilization Management jobs in Ohio are:
What cities in Ohio are hiring for Director Utilization Management jobs? Cities in Ohio with the most Director Utilization Management job openings:
Director, Utilization Management & Operational Integrity
Cleveland, OH • On-site
Full-time
Medical, Dental, Vision, Life, Retirement, PTO
Re-posted 4 days ago
Medical Mutual of Ohio rating
8.6
Based on 17 frontline employees who took The Breakroom Quiz
89th of 301 rated insurance
Job description
Medical Mutual employees must submit their applications through MySource.
Note: This is a hybrid role based in Brooklyn, OH, requiring four days per week on-site.
Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.
Job Summary:
Directs operations related to Commercial and Medicare acute and post-acute care services to advance evidence-based policies, protocols, and practices to ensure efficient use of health care services and adherence to corporate and regulatory standards. Directs education, training, and auditing of all clinical services and operational staff.
Responsibilities:
Qualifications:
Education and Experience:
Professional Certification(s):
Technical Skills and Knowledge:
Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:
A Great Place to Work:
Excellent Benefits and Compensation:
An Investment in You:
About Medical Mutual:
Medical Mutual's status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.
There's a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.
We're not just one of the largest health insurance companies based in Ohio, we're also the longest running. Founded in 1934, we're proud of our rich history with the communities where we live and work.
We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.
#LI-SC1 #LI-HYBRID
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
Note: This is a hybrid role based in Brooklyn, OH, requiring four days per week on-site.
Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.
Job Summary:
Directs operations related to Commercial and Medicare acute and post-acute care services to advance evidence-based policies, protocols, and practices to ensure efficient use of health care services and adherence to corporate and regulatory standards. Directs education, training, and auditing of all clinical services and operational staff.
Responsibilities:
- Analyzes trends and identifies/implements departmental initiatives based upon data provided through the reporting of production, quality, financial and audit data.
- Optimizes processes and workflows to achieve successful quality outcomes and benefit maximization.
- Leads the oversight and management of key performance indicators and monitors and tracks to independently identify over/under utilization patterns and/or deviation from expected results.
- Develops and implements utilization targets and drives accountability to benchmark metrics for staff productivity and membership management
- Oversees the onboarding, education, training, and ongoing monitoring of all Clinical Services & Operations staff, ensuring appropriate decision-making, application of criteria, documentation, and adherence to all regulatory requirements across all lines of business.
- Oversees the recruiting, performance, development and mentoring of staff.
- Ensures that team members are clinically competent and adequately trained to apply medical necessity criteria.
- Provides leadership and support to managers and supervisors.
- Ensures monitoring and tracking tools are in place to adequately link and assess production and quality driven work products and outcomes to individual performers.
- Leads talent management activities to develop and cultivate future leaders.
- Oversees the implementation of processes and systems to improve the efficiency and effectiveness of utilization management for inpatient services.
- Develops effective relationships with key health systems to improve communication, efficiency and effectiveness of utilization review process including leading clinical meetings to facilitate relationship building and identifying opportunities to advance access to EMRs/Portals.
- Serves as the subject matter expert liaison for acute and post-acute service and/or leader on cross-functional teams.
- Initiates cross functional/departmental discussions and initiatives to remove barriers and improve communications and workflows.
- Develops formal policies, procedures and workflows that effectively guide quality of work.
- Performs other duties as assigned.
Qualifications:
Education and Experience:
- Bachelor of Science in Nursing required. Master's degree preferred.
- 8 years progressive experience in managed care utilization management, 5 years of which are in a leadership or project management capacity.
- Experience with process improvement techniques preferred.
Professional Certification(s):
- Registered Nurse with current unrestricted license in state of residency required.
- Ability to obtain Ohio RN or Multi-state RN Compact License within 60 days of date of hire.
- Ability to obtain additional RN licensure for multi-state member management within 90 days of hire.
Technical Skills and Knowledge:
- Comprehensive knowledge of NCQA accreditation standards and CMS regulations, HIPAA compliance and the ability to apply advanced concepts to Company operations.
- Strong computer skills (Microsoft Office, including Outlook, Excel, PowerPoint, Word).
- Demonstrated success with improving achieving productivity for authorization requests.
- Strong demonstrated communication and presentation skills.
- Strong knowledge of clinical claim management including ICD 10, CPT and HCPCS codes.
- Strong knowledge of health insurance benefits and network plan designs.
- Abiltiy to apply knowledge of health plans and industry trends to achieve positive outcomes.
- Thorough understanding of clinical knowledge, members' specific health plan benefits, and efficient care delivery processes.
- Knowledge of care delivery systems and continuum of acute through post-acute care.
Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:
A Great Place to Work:
- We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
- Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
- On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
- Discounts at many places in and around town, just for being a Medical Mutual team member.
- The opportunity to earn cash rewards for shopping with our customers.
- Business casual attire, including jeans.
Excellent Benefits and Compensation:
- Employee bonus program.
- 401(k) with company match up to 4% and an additional company contribution.
- Health Savings Account with a company matching contribution.
- Excellent medical, dental, vision, life and disability insurance - insurance is what we do best, and we make affordable coverage for our team a priority.
- Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
- Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
- After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.
An Investment in You:
- Career development programs and classes.
- Mentoring and coaching to help you advance in your career.
- Tuition reimbursement up to $5,250 per year, the IRS maximum.
- Diverse, inclusive and welcoming culture with Business Resource Groups.
About Medical Mutual:
Medical Mutual's status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.
There's a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.
We're not just one of the largest health insurance companies based in Ohio, we're also the longest running. Founded in 1934, we're proud of our rich history with the communities where we live and work.
We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.
#LI-SC1 #LI-HYBRID
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
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