Southwestern Health Resources

Dallas, TX

Director Utilization Management and Effectiveness Clinical Operations-SWHR CIN

$52-$82 / HOUR

Southwestern Health Resources Clinically Integrated Network (SWHR CIN) seeks to hire a Director Utilization Management and Effectiveness Clinical Operations.

The Director of UM-UE Clinical Operations is responsible for the oversight of the company's UM-UE department including development, implementation, measurement, refinement, ongoing quality improvement and effectiveness of the delegated or non-delegated UM-UE.

This individual demonstrates leadership qualities and is dedicated to advancing the organization's care management strategic initiatives and related health care programs. This leader exhibits proficiency in developing a vision for implementation of strategic plans and operating models to achieve expected performance outcomes in the organization.  This leader demonstrates the ability to communicate effectively across multiple key stakeholders including executives and physicians in the organization

Location: Farmers Branch, TX

Work Schedule

• Full time, day shift

Job Description

 Executes the delivery and oversight of UM-UE programs and services.

Works closely with the Senior Leadership team, Chief Medical Officer, Care Management UM-UE Committee and Quality Committee to evaluate the effectiveness of the UM-UE and health services program. Provides routine reports on interventions and outcomes of the program.

Fosters a spirit of teamwork to produce the best care possible. 

Builds and maintains a strong functional team through effective recruiting, training, coaching, team building, and conducting performance appraisals on a timely basis. 

Provides leadership and management to ensure that the mission statement, core values and core competencies of the organization are put into practice.

Develops and recommends an annual operating budget and submits to Chief Financial Officer for approval. Monitors monthly financial reports for operational areas validating the reports and preparing explanations for variances.

Directs the gathering, evaluation and management of statistical and quantitative data supporting utilization outcomes, managed care outcomes, quality and overall program effectiveness in accordance to company standards and any other applicable quality and CMS standards and regulations.

Develops and monitors goals and milestones designed to further the success of the Utilization Management Program within the framework of the organization's annual goals. Works collaboratively with Provider Relations Risk Adjustment and Quality Management to integrate Care Management initiatives and goals with organizational programs.

Identifies and evaluates potential new programs and services to determine cost effectiveness and revenue potential.

Acts as a champion for the dissemination of the UM-UE Programs throughout the organization. Participates in the development and response for new business opportunities. Provides support and resources for new business implementation.

Collaborates with internal and external entities to improve accessibility standards and quality practice standards to reduce medical costs across the service delivery system (inpatient, emergency departments, urgent care services and practitioner office settings).

Maintains good rapport with physicians, hospital personnel, social services, agencies, etc.. Acts as liaison for company with outside entities and regulatory agencies when required.

Utilizes timely and meaningful financial and utilization reports to assist providers in efforts to alter their care delivery patterns and improve member outcomes.

Assures alignment between health management programs and any related medical practice guidelines or UM-UE criterion. Ensures that medical guidelines are current and valid and communicated to providers as appropriate.

Ensures that policies and procedures meet CMS, NCQA, URAC regulatory and accreditation requirements.

Leads, coaches and develops staff while fostering innovation to improve member outcomes.

Develops, trains and mentors staff members.

Initiates and honors strong service commitments from others by garnering respect and integrity.

The ideal candidate will possess the following qualifications

Bachelor's Degree in Nursing or related healthcare field required and will also consider M.D. or D.O. 

Previous clinical background experience with thorough knowledge of state and federal guidelines, CMS and NCQA, URAC accreditation bodies, participating provider agreements, HIPAA and other related regulatory requirements for Medicare Advantage and Commercial Health Plans as applicable required.
5 years experience in Medicare and or Managed Medicare health care services field required. 5 years experience in the development and execution of clinical programs required. 5 years staff management and leadership experience required

**10 years health care with managed care or health plan experience preferred. Multiple Medicare Advantage payor experience highly preferred ***

Licenses and Certifications
RN - Registered Nurse, or, MD - Medical Doctor, or, DO - Doctor of Osteopathic Medicine required upon hire
Advanced Practice Clinician, Case Management Certification preferred upon hire

Additional Information
  • Location: Dallas, Texas, United States
  • Shift: Day Job
  • Schedule: Full-time
  • Pay Basis: Hourly
  • Minimum Salary:US Dollar (USD) 52.02
  • Market Salary: US Dollar (USD): 39.50
  • Maximum Salary :US Dollar (USD) 82.72