Utilization Management Director jobs in Michigan
Utilization Management Director leads and directs the utilization review staff and function for a healthcare facility. Determines policies and procedures that incorporate best practices and ensure effective utilization reviews. Being a Utilization Management Director manages and monitors both concurrent reviews to ensure that the patient is getting the right care in a timely and cost-effective way and retrospective reviews after treatment has been completed. Provides analysis and reports of significant utilization trends, patterns, and impacts to resources. Additionally, Utilization Management Director consults with physicians and other professionals to develop improved utilization of effective and appropriate services. Requires a master's degree. Typically reports to top management. Typically requires Registered Nurse(RN). The Utilization Management Director manages a departmental sub-function within a broader departmental function. Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure. Deep knowledge of the managed sub-function and solid knowledge of the overall departmental function. To be a Utilization Management Director typically requires 5+ years of managerial experience. (Copyright 2024 Salary.com)
Recently Added Utilization Management Director jobs
- BCBSM Career Section
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Detroit, MI
FULL_TIME
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Provide clinical expertise across the enterprise for various functions. Responsible for corporate and medical policy interpretation, recommendation, and review within recognized areas of responsibility. Advise and collaborate in the development of clinical programs.
Provide clinical support and participate in utilization management, quality management, and care management programs in respective area and identify opportunities for improvement and efficiency.
Assist in the design, development, implementation and assessment of disease state management and health enhancement programs that support the appropriate use of clinical resources in the delivery of consistent high-quality medical care.
Provide clinical leadership for health promotion and education programs and the claims editing department.
Assist in establishing corporate and regional programs to enhance quality of care, reduce medical costs and achieve positive health outcomes.
Serves as clinical resource and subject matter expert to both clinical and non-clinical staff.
Perform clinical reviews and conduct peer to peers.
Conduct discussions with physicians in the BCBSM network regarding: medical policies, utilization management, claims editing, use of resources and quality.
Perform high dollar claims and complex case reviews.
Participate in inter-rater reliability activities.
Participate in committees and workgroups to achieve department and corporate objectives.
"Qualifications"
Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O) required.
Seven (7) years clinical practice experience.
Two (2) years of previous medical director experience working for a health plan, medical group, or hospital in utilization management or medical management preferred.
Current unrestricted state of Michigan Doctor of Medicine (M.D.) or doctor of osteopathy (D.O.) license.
Board certified or board eligible and working towards certification in a specialty approved by the
American Board of Medical Specialists or the American Board of Osteopathy.
Certification in Utilization Review and Health Care Quality & Management is preferred.
Ability to effectively communicate, written and verbally, with external physicians and organizations.
Proven leadership, problem solving, and the ability to manage multiple priorities.
Results oriented and the ability to take ownership for initiatives and collaborate with cross-functional teams to achieve department and corporate goals.
Demonstrated strong computer literacy and proficient in Microsoft Office Suite and web-based programs.
Understanding of health plan functions related to utilization, care, and quality management as well as HEDIS/STARs and NCQA. Familiarity with CMS regulations and standards.
Basic knowledge of evidence-based clinical decision support guidelines (InterQual).
Basic knowledge of CPT coding and guidelines.
Other related skills and/or abilities may be required to perform this job.All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.
- 1 Month Ago
- McLaren Health Care
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Michigan, MI
FULL_TIME
- Position Summary: Responsible for determining the appropriate patient status based on the regulatory and reimbursement requirements of various commercial and government payers in collaboration with th...
- 12 Days Ago
- Corewell Health
-
Caledonia, MI
FULL_TIME
- About Corewell HealthOur new name signals our bold commitment to health and wellness. At our core, we are here to help people be well so they can live their healthiest life possible. Through health ca...
- Just Posted
- Covenant HealthCare
-
Saginaw, MI
FULL_TIME
- UTILIZATION MANAGEMENT SPECIALIST RN(Job Id 19395) Location US:MI:SAGINAW Employment Type EMPLOYEE Post Date 04/15/2024 Description Covenant HealthCare US:MI:SAGINAW 7:00 PM - 7:12 AM, WEEKENDS REQUIR...
- Just Posted
- Corewell Health
-
Southfield, MI
FULL_TIME
- About Corewell HealthOur new name signals our bold commitment to health and wellness. At our core, we are here to help people be well so they can live their healthiest life possible. Through health ca...
- 6 Days Ago
- Corewell Health
-
Grand Rapids, MI
FULL_TIME
- About Corewell HealthOur new name signals our bold commitment to health and wellness. At our core, we are here to help people be well so they can live their healthiest life possible. Through health ca...
- 7 Days Ago
Utilization Management Director jobs at Popular Companies
- Oberon Securities, LLC
-
New York, NY
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-
Columbia, SC
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- Dallas College
-
Dallas, TX
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- Franklin Street
-
Austin, TX
- Franklin Street is currently seeking a Managing Director to lead our Industrial Investment Sales Team in Austin, Texas. ...
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- Bent Tree Partners LLC
-
75010, TX
- Job Description Job Description Project Manager for Agile and SDLC needs
- 4/18/2024 12:00:00 AM
- Hunt
-
Honolulu, HI
- A Brief Overview The Utility Management Director is responsible for providing leadership, direction and guidance as it p...
- 4/16/2024 12:00:00 AM
- Omnicom Media Group
-
New York, NY
- Overview Job Description Annalect's 2,000+ innovators leverage data and technology to help clients across Omnicom build ...
- 4/16/2024 12:00:00 AM
- MacroGenics, Inc.
-
Rockville, MD
- MacroGenics is a leader in the discovery and development of innovative medicines that utilize our next generation antibo...
- 4/15/2024 12:00:00 AM