Director of Care Management, Utilization Management & Appeals

POSITION SUMMARY

The Director of Care Management, Utilization Management, and Appeals role involves overseeing and enhancing our care management programs, utilization management processes, and appeals operations. The ideal candidate will bring a strategic vision and leadership to ensure high-quality, cost-effective care and compliance with regulatory requirements.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

Leadership and Strategy:

• Develop and implement strategic plans for care management, utilization management, and appeals programs.
• Lead and mentor a team of professionals in these areas, fostering a culture of excellence and continuous improvement.
• Collaborate with senior leadership to align departmental goals with the organization�s overall mission and objectives.
• Under the oversight of the CMO, manages budget for programs as well as care model

Care Management:

• Oversee the development and execution of care management programs to enhance member outcomes and satisfaction and reduce total costs of care.
• Ensure that effective care management is integrated into CHOs population health strategy
• Monitor and evaluate care management performance metrics and implement strategies for improvement.

Utilization Management:

• Manage utilization review processes to ensure appropriate use of resources and adherence to clinical guidelines.
• Develop policies and procedures for utilization management that comply with regulatory standards and payer requirements.
• Analyze utilization data to identify trends and opportunities for cost savings and quality improvement.

Appeals Management:

• Oversight of the appeals process to ensure timely and accurate handling of denials and appeals.
• Develop and maintain policies and procedures for appeals management, ensuring compliance with regulatory and contractual requirements.
• Collaborate with clinical and operational teams to resolve complex cases and improve the appeals process.
• Oversight of Appeals Vendor contracts.

Quality and Compliance:

• Ensure all programs comply with federal, state, and local regulations, as well as accreditation standards.
• Implement quality improvement initiatives to enhance the effectiveness and efficiency of care management, utilization management, and appeals processes.
• Stay abreast of industry trends and best practices to maintain a competitive edge.

Collaboration and Communication:

• Work closely with internal and external stakeholders, including healthcare providers, payers, and regulatory agencies, to optimize care delivery and resource utilization.
• Foster strong communication and collaboration among multidisciplinary teams to support integrated care management and utilization management efforts.

JOB SPECIFIC KEY COMPETENCIES (KSAs)

• Ability to adapt and be nimble to effectively problem-solve complex, multifaceted, and/or emotionally charged situations.
• Advanced Skills in Microsoft Products and adaptability to electronic documentation system.
• Excellent communication, writing, analytical and problem-solving skills.

DIVERSITY, EQUITY, AND INCLUSION STATEMENT

Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces:

• Respectful, open communication and cooperation between all employees.
• Teamwork and participation, encouraging the representation of all groups and employee perspectives.
• Balanced approach to work culture through flexible schedules to accommodate varying needs of our people.
• Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other.

QUALIFICATIONS AND CORE REQUIREMENTS

• Bachelor's Degree in related health field, preferred.
• Active and unrestricted Maine (or contract state) clinical license.
• Minimum of 2-3 years of Health Plan Medical Management (Utilization Management and Appeals) experience.
• Leadership experience with working knowledge of human resource principles that promote a positive working environment and adherence to applicable regulatory requirements.