The Vice President of Utilization Management is responsible to the Medical Management Committee for the full range of endeavors required to ensure that all functions of the UM plan effectively meet the goals of the company, to include but not limited to: coordination of UM duties with appropriate personnel to meet program needs; maintain organizational structure and oversight of procedures; membership retention and maintenance; employment, training, and supervision of all UM staff; interpretation of regulatory guidelines; long-term planning including involvement with IPA medical groups and health plans; and act as a resource to all internal and external customers. In the absence of the medical director will support his/her duties and responsibilities by providing oversight ensuring the direction of UM issues to appropriate personnel for resolution. This officer may be asked to assume additional responsibilities as assigned. The Vice President is also responsible for cultivating new leadership for the UM department. Primary Responsibilities:
- Coordinates the Medical Management Committee’s activities and interactions with applicable company and UM. Acts as a resource for problem solving with all departments.
- Responsible for identification of UM function needs and for the preparation of a program including staff duties designed to meet the needs of the company. This involves constant evaluation of the program with recommendations for revision as indicated.
- Responsible for implementing a UM management program that is structured to meet the needs of the patients and is not overly burdensome for the PCP’s to manage. The solicitation of this program to customers must provide a mission for retention of members as well as advocate improvements to market future members with a goal of securing future success of the company.
- Manages staffing ratios of all personnel, the assignment of duties, the supervision of the effectiveness of the UM program related to staff, within the structure of the budget for the department. Ensures staff has access to necessary training relevant to their duties to maximize operational efficiency using all resources available.
- Motivates employees. Key to effectiveness of the Vice President is the ability to motivate and work with staff.
- Responsible for maintaining a continuum in policy that meets national standards and health plan guidelines guaranteeing the effectiveness and success of the UM Program.
- Accountable for disseminating information to the Medical Management Committee regarding UM function and activities of the department.
- Collaborates with leadership team for planning, development, and implementing business projects for overall success of the company..
- Submits a written quarterly analysis of UM activities to the Medical Management Committee and all clients. The information should include effectiveness of UM program and staff, and if indicated, a plan of action to meet UM goals.
- Oversees and ensures that WellMed UM Department adheres to all regulations and contractual agreements. Provides in-services on compliance to better prepare WellMed clinics for audits.
- Responsible for planning the UM budget and all expenditures within the framework of the company budget. This responsibility includes the management of salaries, operating expenses, and UM assets used for daily operations. Participates in the budgeting process by informing the CMO of capital and operating needs.
- Performs other duties at the request of the department head.
- Bachelor of Science in Nursing (BSN) required. (8 additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a bachelor’s degree).
- Active and unrestricted Registered Nurse license in Texas
- 5 or more years of management-level utilization management experience in managed care with HMO health plans
- Progressive experience working with contract language, claims, UM management guidelines and accreditation guidelines
- Demonstrates strong organizational and time management skills
- Ability to delegate assignments with diplomacy
- Strong interpersonal skills with the ability to interact with professional and non-professional staff utilizing effective verbal and written communication skills
- Ability to solve problems and coordinate multiple activities
- Must possess sound knowledge of managed care, NCQA and federal regulations
- Working knowledge of referral processes, claims, case management, contracting and physician practices
- Master’s degree in related field
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Job Keywords: Utilization management; managed care, NCQA, referral processes, claims, case management, contracting and physician practices, San Antonio, TX, Texas