Director of Utilization Management

Develops, manages and directs the Utilization Management programs for the primary care clinics. The key objective is to drive cost-effective, high-quality care with high provider and patient satisfaction. Develops and manages data-driven programs that emphasize appropriate admissions as well as concurrent and retrospective review of care. Responsible for other integrated functions such as Discharge Planning, Case Management program, Outside Utilization Review program and Extended Care Coordination to promote a centralized, coordinated, interdisciplinary process in the continuum of care.

Essential Responsibilities:

• Provides overall direction, design, development implementation and monitoring of utilization programs to meet the utilization goals while maintaining customer satisfaction.
• Analyzes root causes for spikes in utilization in Medicare Part A, B and D. Takes data driven approach when formulating utilization management solutions.
• Creates, manages and updates preferred specialist networks focused on cost-effectiveness and high quality.
• Creates, manages and updates, preferred medication/device formulary.
• Develops and implements disease management interventions to lower cost of care.
• Measures and tracks effectiveness of interventions through KPIs, scorecards and CRM system.
• Analyzes and reports significant utilization trends, patterns, and impact to appropriate departmental and medical staff committees.
• Assures compliance with Federal, State, TJC, NCQA, other regulatory agencies and internal standards and requirements.
• Hires, coaches, trains and disciplines staff to ensure smooth operations in utilization management.
• Also facilitates educational training for medical staff on issues related to utilization management.

• Minimum three years of experience in directing utilization management and discharge planning in a clinic setting,
• Strong acumen in analytics - experience with creating, tracking KPIs and measuring ROI of programs,
• Demonstrated interpersonal, negotiation, and leadership skills.
• Effective oral and written communication skills.
• Up to 50% travel to medical centers across Florida