Director of Utilization/Case Management Job in Ontario 91764, California US
Aveta Health Solutions, a leader in the managed care industry, has an immediate opening for a Director of Utilization/Case Management in Ontario, CA.
RESPONSIBLITIES:
• Responsible for day to day oversight of the Utilization and Case Management process and programs for multiple sites
• Monitors and Directs implementation of the UM process as it relates to the quality of care and assures corrective actions are taken when problems are identified
• Participates in development and design of UM Program, Case Management/Disease Management/Home Health programs and work plans
• Participates in Annual health plan audits for UM/Case Management/Disease Management programs
• Evaluates clinical studies and assists in development of UM/CM/DM plans
• Analyzes UM/CM/DM data and establishes priorities for focused studies (high volume, high risk, high cost) in coordination with the Vice President of Health Services
• Contributes to development and dissemination of evidence based practice guidelines/standards to network providers
• Reviews clinical indicators for ambulatory and inpatient care using accepted national criteria
• Responsible for re-design and monitoring of the case management and UM activities
SKILLS REQUIRED:
• Bachelors degree required, masters preferred (MHA or MBA) or equivalent years of experience or Health Care Administration and/or Managed Care Organization or related field
• Formal training in Medical Management/Utilization Management a plus
• California unrestricted RN license, CPHQ, CCM, or DPUR desired
• Minimum 5 years experience in both Managed Care and UM/MM/CM
• 3 years management experience
• Previous external accreditation experience (NCQA, JCAHO) preferred
• Knowledge of HMO and MCO operations, and continuous quality and utilization/medical management techniques and operations
• Ability to travel to various market sites on a frequent basis
BENEFITS:
Competitive benefits include but are not limited to: Medical, Dental, Vision, Short and Long Term Disability, Life Insurance, Educational Reimbursement, Paid Holidays, 401K, and more!