Director of Utilization Management - Veterans Staffing : Job Details

Insight Global is sourcing for a Utilization Management Director to join a not-for-profit community based healthcare organization within the Operations organization. This position will fall within the Clinical Performance, Operations, and Innovation organization. The Director is responsible for providing strategic guidance to the business, ensuring the company is operating at peak efficiency. This role is a key role in helping our organization provide high quality, equitable care to our rapidly growing membership. The ideal candidate will have HealthPlan experience and understand the offerings of Medicare/Medicaid. This position is 100% remote. Compensation: $120/hr. to $150/hr. Exact compensation may vary based on several factors, including skills, experience, and education. Benefit packages for this role will start on day one of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401K retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.

We are a company committed to creating inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity employer that believes everyone matters. Qualified candidates will receive consideration for employment opportunities without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, disability, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to Human Resources.

Skills and Requirements:

• Experience in a HealthPlan environment, working with business executives for strategic planning.
• Experience with MA HealthPlan offerings & benefits, SCO experience is a plus.
• Understanding of insurance processes such as appeals and processing denials.
• Experience and understanding of compliance with medical policy and CMS regulations/requirements.
• Understanding of Medicare/Medicaid compliance with all federal, state, and local regulatory guidelines.
• Support the development of utilization management policy initiatives.
• Support the development and implementation of medical policy, including recommendations for modifications to enhance efficiency and effectiveness.