Director, Utilization Management

Director, Utilization Management

Job Summary:

The Director of Utilization Management (UM) plays a pivotal role in overseeing the efficient use of resources both within and outside ArchWell Health, ensuring members receive high quality and cost-effective care. This position will also assist in the implementation of Utilization Management project and processes across the organization. This position will monitor and evaluate healthcare utilization trends, identify areas for improvement, and collaborate with market leaders and colleagues to make recommendations and help implement UM initiatives. An ideal candidate will have a deep understanding of utilization management and have a demonstrated history of partnering with cross-functional stakeholders to drive projects and business initiatives to completion.

Duties/Responsibilities:

• Participate in planning and management of UM projects across the enterprise, including setting targets, delegating tasks, and developing tracking capabilities to ensure the timeliness of project completion.
• Scrub data and prepare analysis and reports to provide meaningful information and resources to market leadership and key stakeholders.
• Assist in implementation and monitoring of UM initiatives and utilization review systems for both Medicare Part A and Part B programs.
• Partner cross-functionally to help evaluate and identify solutions to UM-related issues across the enterprise.
• Help coordinate efforts to drive effective referral and Network management across the enterprise, including collaborating with markets to create and maintain a preferred provider list.
• Collaborate with markets to build and sustain effective communication strategies with specialty groups to align with value-based care model.
• Develop and implement effective Utilization review processes.
• Develop and monitor success metrics for Utilization review processes.
• Maintain strong knowledge of external trends and regulations, as well as internal UM policies and processes.
• Communicate effectively with local leadership to roll out UM initiatives and updates.
• Monitor and evaluate healthcare utilization trends, identifying areas for improvement and collaborating with market leaders to advise of recommended action needed.
• Evaluate and monitor current process effectiveness and help coordinate pilots and new processes within the enterprise.

Required Skills/Abilities:

• Ability to manage and deliver strategic projects, communicate project status and risks to stakeholders
• Strong knowledge of Utilization Management in a value-based care setting.
• Ability to define problems and identify optimal solutions under tight deadlines.
• Self-motivated with excellent verbal and written communication skills with all levels of leadership.
• Excellent interpersonal and communication skills.
• Ability to drive accountability and process changes without direct accountability
• Strong data analysis ability.

Minimum Qualifications:

• Bachelor's degree in healthcare administration, healthcare information systems, or related field, preferred
• Minimum of 7 years of experience in utilization management, healthcare operations, project management, or related field
• Ability and willingness to travel up to 25% at peak times
• Embodies and serves as a role model of ArchWell Health's Values:
  
  
  
  • Be compassionate
  • Strive for excellence
  • Earn trust
  • Show respect
  • Stay resilient
  • Always do the right thing
  
  
  
  

About ArchWell Health:

At ArchWell Health, we're creating a community of caring designed to help our members stay healthy and engaged. By focusing on a strong provider-patient relationship, routine wellness, and staying active, our members enjoy a higher level of care and better quality of life after the age of 60. Everything we do is for seniors. We believe seniors should be heard, listened to, and given ample time by their physicians to live well later in life.

Our value-based care model is designed to prevent illnesses while keeping members healthy and happy in every aspect of their life. We deliver best-in-class primary care at comfortable, accessible neighborhood centers where older adults can feel at home and become part of a vibrant, wellness-focused community. We're passionate about caring for older adults and united by the belief that caring has the power to change everything for our members.

ArchWell Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to their race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected classification.

Last Updated: 01/07/2025