Director of Utilization Management

Job Description

Job DescriptionOrganizational Description

The Community Health Center Network (CHCN), sister organization to the Alameda Health Consortium, is made up of the eight federally qualified community health centers in Alameda County. CHCN functions as the managed care MSO for our health centers, contracting with the Alameda Alliance for Health. In order to help our health centers meet their missions of providing the best possible care to their communities, we also provide a broad range of training, technical assistance, quality improvement, information technology, and data analytic services.

Position Title: Director of Utilization Management

Department: Utilization Management (UM)

Reports To: Chief Medical Officer

Classification: Exempt

Status: Full Time (Regular), Remote/Hybrid

POSITION SUMMARY

The Director of Utilization Management (UM) provides strategic and clinical leadership for the UM department, ensuring effective medical review processes, regulatory compliance, and high-quality member care. This role is responsible for setting the direction of UM programs, leading multi-disciplinary teams, and serving as the primary liaison with internal executive leadership, regulatory agencies, and external partners such as health plans and providers. The Director ensures the integration of UM policies with organizational goals, leads audit and compliance strategies, and partners closely with senior leadership to drive continuous improvement in care delivery and resource utilization.

ESSENTIAL POSITION RESULTS

The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may perform other duties as assigned.

· Provide oversight for utilization management including representation at health plan meetings and audits, and development and maintenance of utilization management plan, policies, procedures, and reports.

· Set department policies and ensure alignment with regulatory updates and industry best practices.

· Collaborate with cross-functional leaders (e.g, Case Management, Quality, Provider Services, Claims, IT) to improve clinical workflows and outcomes.

· Provide UM performance updates to senior leadership, including trend analysis, risk mitigation strategies, and program improvements.

· Responsible for effectively managing the UM and BCM programs including program development, staff training and support, and work with external partners.

· Supervise UM Associate Director and UM Regulatory Nurse Specialist and provides administrative support in timecard management, quarterly check-ins, education, staff development, work allocation and/or problem resolution.

· Collaborates with UM Manager and UM Medical Director to develop reports for the monthly Clinical Committee.

· Work with team to support quality improvement program studies, access audits, and member/provider satisfaction surveys.

· Provides oversight of all internal and external audit findings and audit responses.

· Develops corrective action plans and collaborates with the UM Regulatory Nurse Specialist and UM Associate Director in audit preparation and implementation of corrective action plans.

· Provides oversight of the timely review and submission of regulatory reports, annual policy review, and required annual staff development trainings.

· Serve as the medical management representative at CHCN internal and external meetings and audits.

· Ensures compliance with CHCN policies, regulatory/accreditation (NCQA, DHCS, CMS, DMHC, etc.) and health plan requirements.

· Develops and implements departmental goals that support CHCN’s strategic plan, goals, and mission.

· Responsible for annual department budget creation.

· Collaborate with the Chief Medical Officer and Chief Operating Officer on strategic planning and goals for the UM program and CHCN as an organization.

HIPAA Designated Access

“For the purposes of the job duties of this position, the person in this position requires access only to the following HIPAA protected information data sets”

X

1. MSO Membership

X

2. MSO Claims

X

3. MSO Referral/Auth

X

4. MSO Capitation

5. Data Warehouse

X

6. Chart Audit/QI

SUPERVISORY RESPONSIBILITIES

Associate Director of UM

UM Regulatory Nurse Specialist

MINIMUM QUALIFICATIONS

Education & Experience

· Active, unrestricted, California Registered Nurse (RN) license

· 5+ years in Utilization Management / Quality Improvement in hospital, HMO, or IPA setting.

· 3+ years in health care delivery at hospital, clinic, or physician’s office.

· Good communication and customer relation skills.

· Utilization Management/ Quality Improvement experience.

· Management experience necessary.

· Computer literacy.

· Sound decision-making skills for clinical and non-clinical issues.

· Training skills.

· California driver’s license and reliable transportation required.

General CHCN Roles:

· Fosters an environment that promotes trust and cooperation among clients and staff.

· Enforces policies and procedures, including maintenance of client confidentiality, to ensure that the principles of CHCN are implemented.

· Accountable for participating in decision making processes and understanding the outcome(s).

· Understands the values and principles of CHCN and applies them in work responsibilities.

· Participates in outreach activities, agency advocacy, and serves on ad hoc committees, as requested.

· Attends CHCN and Board of Directors meetings, as required.

CERTIFICATES AND/OR LICENSES

Active CA RN without limitations/restrictions

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and use hands to finger, handle, or feel. The employee is frequently required to talk or hear. The employee is frequently required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.

WORKING CONDITIONS AND ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly exposed to an inside/outside environment.

The Community Health Center Network is an Equal Opportunity Employer.