Utilization Management Director jobs in Detroit, MI
Utilization Management Director leads and directs the utilization review staff and function for a healthcare facility. Determines policies and procedures that incorporate best practices and ensure effective utilization reviews. Being a Utilization Management Director manages and monitors both concurrent reviews to ensure that the patient is getting the right care in a timely and cost-effective way and retrospective reviews after treatment has been completed. Provides analysis and reports of significant utilization trends, patterns, and impacts to resources. Additionally, Utilization Management Director consults with physicians and other professionals to develop improved utilization of effective and appropriate services. Requires a master's degree. Typically reports to top management. Typically requires Registered Nurse(RN). The Utilization Management Director manages a departmental sub-function within a broader departmental function. Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure. Deep knowledge of the managed sub-function and solid knowledge of the overall departmental function. To be a Utilization Management Director typically requires 5+ years of managerial experience. (Copyright 2024 Salary.com)
Recently Added Utilization Management Director jobs
- BCBSM Career Section
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Detroit, MI
FULL_TIME
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Provide clinical expertise across the enterprise for various functions. Responsible for corporate and medical policy interpretation, recommendation, and review within recognized areas of responsibility. Advise and collaborate in the development of clinical programs.
Provide clinical support and participate in utilization management, quality management, and care management programs in respective area and identify opportunities for improvement and efficiency.
Assist in the design, development, implementation and assessment of disease state management and health enhancement programs that support the appropriate use of clinical resources in the delivery of consistent high-quality medical care.
Provide clinical leadership for health promotion and education programs and the claims editing department.
Assist in establishing corporate and regional programs to enhance quality of care, reduce medical costs and achieve positive health outcomes.
Serves as clinical resource and subject matter expert to both clinical and non-clinical staff.
Perform clinical reviews and conduct peer to peers.
Conduct discussions with physicians in the BCBSM network regarding: medical policies, utilization management, claims editing, use of resources and quality.
Perform high dollar claims and complex case reviews.
Participate in inter-rater reliability activities.
Participate in committees and workgroups to achieve department and corporate objectives.
"Qualifications"
Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O) required.
Seven (7) years clinical practice experience.
Two (2) years of previous medical director experience working for a health plan, medical group, or hospital in utilization management or medical management preferred.
Current unrestricted state of Michigan Doctor of Medicine (M.D.) or doctor of osteopathy (D.O.) license.
Board certified or board eligible and working towards certification in a specialty approved by the
American Board of Medical Specialists or the American Board of Osteopathy.
Certification in Utilization Review and Health Care Quality & Management is preferred.
Ability to effectively communicate, written and verbally, with external physicians and organizations.
Proven leadership, problem solving, and the ability to manage multiple priorities.
Results oriented and the ability to take ownership for initiatives and collaborate with cross-functional teams to achieve department and corporate goals.
Demonstrated strong computer literacy and proficient in Microsoft Office Suite and web-based programs.
Understanding of health plan functions related to utilization, care, and quality management as well as HEDIS/STARs and NCQA. Familiarity with CMS regulations and standards.
Basic knowledge of evidence-based clinical decision support guidelines (InterQual).
Basic knowledge of CPT coding and guidelines.
Other related skills and/or abilities may be required to perform this job.All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.
- 1 Month Ago
- UHS
-
DEARBORN, MI
FULL_TIME
- Responsibilities Utilization Management Case Manager Beaumont Behavioral Health (a UHS Facility) A growing 144-bed behavioral health facility – Beaumont Behavioral Hospital provides a full continuum o...
- 15 Days Ago
- Integra Partners
-
Troy, MI
FULL_TIME
- Integra is looking for a LPN/LVN experienced in the managed care payor environment to perform pre-service and post-service utilization reviews and appeals for DMEPOS. This individual will play a key r...
- 16 Days Ago
- FRIEDMAN MANAGEMENT COMPANY
-
Farmington, MI
OTHER
- Job Details Level: Management Job Location: Corporate Office - Farmington Hills - Farmington Hills, MI Position Type: Full Time Salary Range: Undisclosed Job Shift: Day Job Category: Management Descri...
- 29 Days Ago
- Clinical Management Consultants
-
Detroit, MI
FULL_TIME
- An exciting opportunity is available in the greater Detroit area for a Market Director Case Management. This is your chance to become a part of a nationally recognized healthcare system who has been p...
- 1 Month Ago
- Henry Ford Health System
-
Troy, MI
FULL_TIME
- GENERAL SUMMARY:Responsible for handling of daily pharmacy duties such as drug claim adjudication issues, prior authorization, and pharmacy benefit inquiries from members/patients, physicians, pharmac...
- 1 Month Ago
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0 Utilization Management Director jobs found in Detroit, MI area
- Publicis Groupe
-
Birmingham, MI
- Company Description Digitas is the Networked Experience Agency, built on the vision that we create magnetic experiences ...
- 4/26/2024 12:00:00 AM
- Early Start Childcare Llc
-
Detroit, MI
- Job Description Job Description Benefits/Perks Competitive Compensation Paid Time Off Career Growth Opportunities Job Su...
- 4/26/2024 12:00:00 AM
- Murtech Staffing and Solutions
-
Detroit, MI
- Job Description Job Description Job Title: Group Director, Case Management Location: DMC Detroit, Michigan (Relocation a...
- 4/25/2024 12:00:00 AM
- R1 RCM
-
Detroit, MI
- Sr. Director, Product Management - Coding The Sr. Director of Product will be responsible for both strategic and tactica...
- 4/25/2024 12:00:00 AM
- Detroit Medical Center Shared Services
-
Detroit, MI
- The Detroit Medical Center (DMC) is a nationally recognized health care system that serves patients and families through...
- 4/24/2024 12:00:00 AM
- Wayne State University
-
Detroit, MI
- Associate Director, Endowment ManagementWayne State University is searching for an experiencedAssociate Director, Endowm...
- 4/23/2024 12:00:00 AM
- Dmc Receiving Hospital
-
Detroit, MI
- POSITION SPECIFIC RESPONSIBILITIES: Department Operations Maintains an adequate number and skill mix over seven days a w...
- 4/23/2024 12:00:00 AM
- Burns & Wilcox
-
Farmington Hills, MI
- Burns & Wilcox is seeking a dynamic, forward-thinking leader to drive strong and sustainable growth in our Michigan regi...
- 4/22/2024 12:00:00 AM
About Detroit, Michigan
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