Previous Job
Director, Care & Utilization Management
Ref No.: 17-00892
Location: Brooklyn, New York
Title: Director, Care & Utilization Management
Location: Brooklyn, NY
Duration: RTH or Direct hire

Responsibilities and Qualifications:

Oversees the care and utilization management operations for one or more of the Health Plan product lines. Collaborates with product line senior leadership in the development of the departmental strategic goals and objectives consistent with the overall strategic goals and financial targets. Ensures implementation of Quality Improvement (QI) programs and initiatives related to care and utilization management and service operations to ensure services provided meet the needs of the member. Works strategically to advance status as a World Class health plan to the community and regulatory agencies. Ensures compliance with all Federal & State Regulations and Requirements and Corporate Policies related to prospective, concurrent, and retrospective care and utilization management processes. Works under limited direction.

Licensure: License and current registration to practice as a Registered Professional Nurse (RN) in New York State required.

Education: Bachelor's degree in Nursing required. Master's degree in Nursing preferred.

Experience: Minimum eight years of clinical nursing experience, including a minimum of two years in a managed care/HMO organization, required. Minimum two years managerial experience over a managed care medical management system required. Experience with State and external accreditation managed care audits and reviews required. Experience with Health Plan Employer Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and Health Outcome Surveys (HOS) required. Experience with Quality Assessment and Process Improvement (QAPI) projects required. Experience with writing and implementing program level policy and procedures required. Proficient with computer and software programs (e.g.; Microsoft Word, Excel) and the Internet required. Experience applying medical management treatment guidelines, such as InterQual / McKesson, Milliman, or other practical management guidelines required.