Director of Operations Utilization Management

Apply now

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary

The Director of Utilization Management (UM) Operations is accountable for developing and maintaining the framework to achieve efficient and effective operational processes, policies and procedures to support the department’s performance and quality metrics. This includes responsibility for robust performance measurement monitoring and reporting for both clinical and non-clinical functions within UM and across all products to ensure specific targets and goals related to people, process and data/technology are met. The Director is also accountable for the continuous assessment of UM program operations, identifying opportunities for improvement, assessing risk and communicating observations, recommendations and results to the VP of UM. In conjunctions with the Director of Clinical UM, the incumbent is responsible for identifying ways to integrate UM functions across the organization to create efficient workflows and handoffs as needed including integration with delegated vendors.

The Director leads and is accountable for the performance of a team of non-clinical staff including Prior Authorization, Inpatient UM specialists and Correspondence Coordinators.

Our Investment In You

• Full-time remote work
• Competitive salaries
• Excellent benefits
  
  

Key Functions/Responsibilities

Process

• Develops, implements and evaluates departmental policies, processes and procedures that ensure efficiency, effectiveness, quality and consistency and meet regulatory requirements.
• Develops and monitors performance and quality metrics, including audits and call monitoring. Notifies the VP of UM if performance falls below expectations, and works with leadership to develop a plan to improve performance.
• Leads and oversees the UM component of highly visible and complex initiatives (new software applications, upgrades, UM cost savings projects).
• Manages and ensures regulatory and accreditation UM standards for turnaround and documentation
• Ability to facilitate and implement new system implementation and upgrades including UAT and Quality testing.
• Analyzes metrics and other information to substantiate results.
• Proactively identifies opportunities to improve existing processes or add new processes and recommends/proposes solutions to improve outcomes across the department. Anticipates downstream impacts of workflow/ process changes to UM department and other departments in the end to end process.
• Oversees the timely and accurate production of regulatory and contractual reporting
• Acts as a liaison to Legal, Compliance and Quality Department on issues that have both legal risk and compliance aspects and coordinates with the Accreditation Manager on NCQA audits as well as supporting all corrective actions in assigned area.
• Assists the VP of UM in development and management of the department budget
• Represent BMCHP/Well Sense UM operations externally as appropriate such as meetings with provider groups and state agencies.
• Attends various UM Committee meetings, as well as other departmental/organizational meetings
  
  

People

• Develops a high performance team as evidenced by
• Meeting all process requirements
• Eliciting the team’s participation in identifying opportunities for improvement
• Meeting defined team goals such as targeted results of an annual team survey
• Developing performance management skills in supervisory staff by modeling, managing, and setting clear expectations
• Develops and oversees Utilization Management staff onboarding and ongoing role specific training, in conjunction with Clinical Manager of Utilization Management and OCA Trainer.
• Oversees the development and execution of individual professional development plans for all direct reports consistent with the corporate performance management program.
  
  

Data/Technology

• Oversees the consistent use of support technologies
• Develops reporting with Analyst by thoroughly understanding needs, purpose and requirements
• Develops departmental targets, measures and metrics and integrates their meaningful use across all department functions and team members
• Continuously evaluates tools and technologies to identify new opportunities for efficiency or effectiveness across all staff in the department
• Works with other business areas including IT, Clinical Informatics, and Quality as related to business requirement development , clinical management software configuration, and UA
  
  

Supervision Exercised

• Directly manages 2-5 staff and indirectly manages 40-45 FTEs.
  
  

Supervision Received

• General supervision is received weekly from VP of UM.
  
  

Education

• Master’s Degree in Healthcare or related field preferred
  
  

Experience

• 7 or more years of management operations experience
• 3 or more years of experience with Medicaid/Medicare Managed Care or other health plan experience
  
  

Preferred/Desirable

• Healthcare systems experience
• Health plan or insurance environment experience
• Vendor experience
• Experience in an operations environment with regulatory turnaround times.
• Experience managing cross functional projects.
  
  

Certification Or Conditions Of Employment

• Pre-employment background check
  
  

Competencies, Skills, And Attributes

• Experience managing complex processes
• Attention to detail
• Ability to meet aggressive time lines when required
• Ability to develop a high functioning team
• Experience with data driven decision making
• Knowledge of metrics, and an ability to compile, format, interpret, and present data
• Mastery of verbal and written communication skills, including but not limited to the ability to translate complex subject matter into understandable information tailored to specific audiences
• Ability to successfully plan, organize, implement and manage projects within a health care setting.
• Strong working knowledge of Microsoft Office applications
• Aptitude for matching business requirements to potential software solutions
• Strong analytical and problem solving skills.
• Knowledge of process improvement techniques.
  
  

Working Conditions And Physical Effort

• Regular and reliable attendance is an essential function of the position.
• Work is normally performed in a typical interior/office work environment.
• No or very limited physical effort required. No or very limited exposure to physical risk.
  
  

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

Apply now