PacificSource Health Plans

  • Director, Utilization Management

    Job Location US-OR-Bend
    Job ID
    Regular Full-Time
    Hiring Pay Range
    # of Openings
  • Overview

    Lead the respective managers and teams in the ongoing internal and external health services operations as related to Utilization Management process. 


    Responsible for utilization management across all Lines of Business (LOBs). Facilitate, guide, create, and monitor data and relevant analytics for ongoing operations and regulatory oversight bodies.  Participate and prepare appropriate materials for relevant committees and oversight bodies.  Promote and oversee audit processes and assist in identification and resolution of gaps. Lead the staff and processes to effectively improve our customer service and provides leadership and direction to our team through the promotion and training of LEAN project management.  Work collaboratively with internal and external community entities and in the implementation of quality improvement measures and process transformation initiatives.


    1. Manage and improve the performance of the Utilization Management department through effective oversight and coaching of teams, managing team performance, monitoring daily workflow, and improving processes and outcomes.
    2. Monitor, evaluate, and report performance for the teams relating to volumes, timelines, accuracy, customer service, and other performance objectives, including regulatory compliance.
    3. Responsible for improvement of engagement scores across LOBs. Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.
    4. Oversee and assist in providing exceptional service and information to members, providers, employers, agents, and other external and internal customers.
    5. Standardize systems, processes, and policies across the company, where feasible. Continually seeks to improve quality of service, care, and processes for internal and external customers.
    6. Responsible for process improvement and working with other departments to improve interdepartmental processes. Utilize LEAN methodologies for continuous improvement.  Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.
    7. Identify costs and benefits of Utilization Management programs inter- and intra-departmentally.
    8. Participate in relevant compliance activities, audits and reporting. Support related PacificSource departments, facilitate audit processes and assist in the identification and resolution of gaps.
    9. Ensure internal departmental awareness, inclusion, and deployment of relevant CMS, Oregon Health Authority, and other relevant regulatory bodies’ rules and guidelines.
    10. Serve as liaison with all PacificSource departments to coordinate optimal provision of service and information. Participate in management planning, Request for Proposals (Medicare/Medicaid applicable oversight), complete annual reports as required by states we serve.
    11. Ensure that medical benefits are administered consistently to meet contract obligations and to ensure regulatory compliance. Review and edit Prior Authorization grid annually including expected Return on Investment.
    12. Work in concert with Compliance and Product Developments in the development of handbooks, contracts and benefit summaries.
    13. Accountable for accurate reinsurance and/or stop loss and large case reporting to reinsurer, Executive Management and Medical Director(s). Identify and inform Medical Director(s) of complex cases and/or potential reinsurance claims. Keep the Medical Director(s) apprised of medical management issues.
    14. Maintain oversight of applicable quality regulations and certifications. Remain current in specialty field and keep apprised of current and anticipated trends in medical management. Maintain excellent working knowledge of Medicare and Medicaid Governmental rules and regulations as well as those applicable to the Commercial LOB, to ensure that project operations remain compliant. Present and document pertinent information to support project recommended action plans.
    15. Provide for operational excellence through management reports, up-to-date systems, and strategic initiatives. Develop policies, procedures, guidelines, and other operational protocols for the Health Services department. Inform the development, monitoring and implementation of pertinent policies and procedures for Health Services within CMS, PPACA, NCQA, HIPAA and State/Federal requirements.
    16. Monitor caseloads and workflow of all staff to assure appropriate distribution and processing of tasks.
    17. Evaluate and recommend systems additions and upgrades as appropriate. Work with IT and Analytics on prioritization of software changes and needed Informatics upgrades. Liaison between Medical Directors and IT / Informatics / Analytics to support appropriate reporting packages for internal and external use.
    18. Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
    19. Act as primary liaison with Commercial and Government operations. With Medical Directors, act as liaison and resource for Provider-Payer partnerships. Actively pursue partnerships and build relationships with key healthcare stakeholders in the communities served by PacificSource.
    20. Work collaboratively with the Case Management Director to ensure seamless care transitions across the care continuum and to establish best practice strategies for managing members across LOBs.
    21. Responsible for oversight, management, development, implementation, and communication of department programs. Develop annual department budgets. Monitor spending versus the planned budgeted throughout the year and take corrective action where needed.
    22. Manage Health Services contracts, their data, and required reporting to meet regulatory and business needs.
    23. Work with and coordinate with relevant parties to review of post – care costs audits for accuracy of billing and coding.
    24. Work / coordinate with Marketing and Communications with preparation and review of member – facing communications.

    Supporting Responsibilities:

    1. Work with Medical Directors in responding to inquiries or complaints and pertinent report preparation for other review functions.
    2. Actively participate as a key team member in Manager/Supervisor meetings.
    3. Participate in and support project teams led by other departments and provide necessary input to support the goals of colleagues.
    4. Meet department and company performance and attendance expectations.
    5. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
    6. Perform other duties as assigned.


    Work Experience: At least seven years of experience with varied medical exposure required. Minimum of 3 years management or supervisory experience required.   Experience with Medicaid and Medicare clinical operations in health plans is required.  Experience in case management, disease management, utilization management and program development using evidence based medicine required.  Experience in Medicare bid process and benefit design is preferred. Prior success in healthcare integration, process development and program implementation is desirable.  Additional experience managing complex work processes, including, HEDIS, 5 Star and HCC related projects is highly preferred.


    Education, Certificates, Licenses: Bachelor degree in health services administration or related field required. Registered nurse with current unrestricted state license required. Maintains current clinical knowledge base and specialty nurse functions. Certified Case Manager (CCM) as accredited by CCMC (The Commission for Case Management Certification), or equivalent.


    Knowledge: Knowledge and understanding of disease prevention, medical procedures, care modalities, procedure codes (including ICD-10 and CPT codes,), health insurance, and CMMS / State of Oregon mandated benefits. Ability to develop, review, and evaluate utilization reports. Knowledge of and demonstrated experience with quality improvement methodology. Experience giving presentations. Organizational skills with solid experience in using computers and various software applications including Microsoft Office Suite, SharePoint, Claims and Care management programs, and audio-visual equipment. Ability to work independently with minimal supervision.  Ability to deal with members, patients and families at all levels of care and/or crisis. Thorough knowledge of community services, providers, vendors and facilities available to assist members. Ability to supervise and manage a regular staff and a professional nursing staff. Continually seeks to improve quality of service, care, and processes for internal and external customers. 



    Our Values

    • Authenticity
    • Building Organizational Talent
    • Coaching and Developing Others
    • Compelling Communication
    • Customer Focus
    • Empowerment/Delegation
    • Emotional Intelligence
    • Leading Change
    • Managing Conflict
    • Operational Decision Making
    • Passion for Results


    • We are committed to doing the right thing.
    • We are one team working toward a common goal.
    • We are each responsible for our customers’ experience.
    • We practice open communication at all levels of the company to foster individual, team and company growth.
    • We actively participate in efforts to improve our many communities-internally and externally.
    • We encourage creativity, innovation, continuous improvement, and the pursuit of excellence.


    Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 30% of the time.


    Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions.  Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.


    Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.


    PacificSource is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.



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