Director, UM (Finance)

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Director Utilization Management is responsible for the provision of leadership, direction, oversight, and operations management for the Organization's Utilization Management (UM) functions across all markets for AHP. Interprets key performance metrics to develop plans, mobilize the work force, and achieve the Organization's UM outcomes relative to the Triple Aim (improved population health, improved experience of care, and lower healthcare costs). Accountable for the strategic and operational excellence of the UM function within Clinical Services including administrative and care cost initiatives, system development and delivery of high-quality outcomes, compliance with all state and federal regulations that affect UM activities and executive level reporting and communication as needed. Builds and maintains strong collaborative partnerships with key partners in the Clinical Services organization including Care Management, Performance Improvement, Medical Management and Policy including Quality and Medical Review and Appeals, Pharmacy, and Provider Integration to identify, develop, implement, and monitor performance metrics related to UM Operations. Builds strong collaborative partnerships internally and externally with key stakeholders and vendors to ensure that internal and external UM operations programs are well-coordinated and work cooperatively to achieve outcomes goals. Areas of direct responsibility include Medical Utilization Management including Inpatient Review & Prior Authorization, SNF concurrent review, and pre-service authorization process.

GENERAL DUTIES/RESPONSIBILITIES
1. Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.
2. Participates in strategic planning and in the establishment of strategic directions and goals for all clinical services operations.
3. Participates in the establishment, monitoring, and reporting of key metrics to manage performance related to clinical services processes and functions.
4. Accountable for achieving established outcomes goals relative to UM operations.
5. Builds alliances across the business and clinical leadership teams with the end objective of a collaborative, efficient and viable operating model.
6. Innovates and implements new or revised models for the Organization's UM operations functions in response to evolving trends in healthcare delivery and/or emerging models of care.
7. Serves as a change agent, assisting others in understanding the importance, necessity, impact and process of change through active involvement in decision making and coaching of leaders and staff.
8. Utilizes proven performance improvement methodologies and incorporates a strong emphasis on data to drive the implementation of improvements in the Organization's UM operations and organizational culture in order to achieve improved outcomes metrics relative to the Triple Aim (improved population health, improved experience of care, and lower healthcare costs).
9. Accountable for maintaining updated, current competencies, knowledge and skills in healthcare management trends, legal/regulatory and accreditation standards, and payer-based best practices in medical management and for the application of such current concepts within the Organization's clinical operations strategies, processes and functions.
10. Accountable for leadership and oversight of front-line UM operational organization including care manager RNs, Medical Review RNs, and non-clinical customer service reps.
11. Other duties as assigned or requested.

upervisory Responsibilities:

Oversees assigned staff. Responsibilities include recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees.

Job Requirements:

Experience:

• Required: Minimum 10 years of experience in clinical services or health plan care management functions with at least 5 years of experience in a leadership position. Minimum of 5 years of experience in case management, utilization management, and population health

• Preferred: Clinical leadership experience in multiple settings of care (e.g. ambulatory, acute and post-acute care). Clinical leadership experience in both the provider setting and in health plan or payer settings

Education:

• Required: High School Diploma or GED. Bachelor's degree or Masters Degree or four years additional experience in lieu of education.

• Preferred: Bachelors in BSN, PA, or business related (Business, Health Administration).

Training:

• Preferred:

Specialized Skills:

• Required:

• Solid knowledge of best practices in all aspects of medical management
• Ability to use medical management metrics and to develop data-based initiatives designed to improve outcomes relative to the Triple Aim
• Ability to lead and motivate clinical and administrative groups to achieve specific objectives Preferred
• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
• Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly
• Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Report Analysis Skills: Comprehend and analyze statistical reports.

Licensure:

• Required: None

• Preferred:

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
Pay Range: $113,332.00 - $169,999.00

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/ . If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health's talent acquisition team, please email careers@ahcusa.com .