Director, Utilization Management
Community Health Choice, Inc. (Community) is a non-profit Health Maintenance Organization (HMO) licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 70 hospitals, Community serves over 260,000 Members with the following programs:
• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
Skills / Requirements
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.
• 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.
• Microsoft Office, MS Excel.
• Strong analytical and research skills.