Director, Utilization Management & Operations

See more jobs from Christian Care Ministry Inc

3 months old

This job is no longer active

The range for this role is $114,000 - $164,000  

Actual base pay will be determined based on a successful candidate's work location, skills/abilities, experience, and education. This role includes opportunity to receive an annual bonus target of 15% of annual eligible earnings. Actual bonus amounts are determined by length of time in role, individual performance, and organizational performance.

Interested candidates must be willing and able to work onsite full-time in either our Melbourne, FL or Orlando, FL office.  

The Mission

At Christian Care Ministry we believe that Christians can, and should, share in one another’s burdens. Through the use of Medi-Share®, a healthcare sharing ministry for Christians, we cultivate that belief.

The Team

Everyone at Christian Care Ministry is in agreement with our Statement of Faith, which outlines our core beliefs. Although we aren’t perfect people, we are serving our perfect God to the best of our ability.

The Job

The Director, Utilization Management and Operations will oversee the direction and provide leadership to clinical and clinical support staff to support positive health and financial outcomes of Medi-Share membership in accordance with the member-voted Guidelines. This role will design and develop clinical strategies to achieve and maintain optimal wellness outcomes and make decisions related to identifying and resolving complex technical and operational problems within the healthcare experience. The Director, Utilization Management and Operations ensures the delivery of high-quality, cost-effective care to members through effective care coordination and case management.

Essential Job Duties & Responsibilities

  • Oversee the Care Management function that assists Medi-Share members in achieving an optimal level of wellness and coordination of their care; helping them identify cost-effective and non-duplicative services while they are in a time of great need and potential crisis
  • Develop and ensure the effective delivery of education to members regarding the provisions of their Program Guidelines relative to healthcare, nursing, rehabilitative, and spiritual services
  • Provide direction to Care Management staff including, but not limited to hiring, training, and communication regarding policy and procedural changes and monitoring and evaluating the quality of all processes
  • Perform and/or administer research in ensuring effective, timely responsiveness to Care and Case Management issues; if required, handoff to Chief Medical Officer, providing required research and recommendation summary
  • Act as liaison between member and/or provider to bring about resolution when conflicts arise
  • Maintain awareness and be alert to member and provider issue trends and escalating concerns, and recommend resolutions
  • Collaborate with other internal teams and stakeholders to ensure timely and accurate determination of sharable services
  • Define and manage pre-service eligibility determinations (EDI 278) and associated standard operating procedures
  • Define and manage concurrent review processes to effectively manage length of stay and facilitate discharge planning
  • Oversee the preparation of various telephone scripts
  • Update and maintain the policy and procedure manual
  • Maintain the High Priority queue in conjunction with fellow Directors and Chief Medical Officer
  • Assist in developing projects, policies, procedures, and other related issues as required
  • Support the strategic vision delineated by the Chief Medical Officer and the Ministry
  • In coordination with the Chief Medical Officer, organize and staff the Department in a manner that provides optimal service to the members and membership
  • Ensure department Managers are successful in workforce, quality, and performance management (as elsewhere delineated)
  • Define performance and attendance expectations of department Managers
  • Review weekly performance reports submitted by department Managers
  • Submit monthly performance reports to the Chief Medical Officer of all staff under Director
  • Contribute to the exercise and expression of Christian Care Ministry’s Christian beliefs
  • All other duties as assigned

Essential Skills & Abilities

  • Sound understanding of population health, stratification, and case management principles
  • Ability to lead by example, motivate and encourage, be a self-starter, organized, enthusiastic, anticipate and apply systematic planning, prioritize and delegate tasks appropriately, and display diplomatic firmness
  • Excellent oral and written communication skills
  • Interpersonal and intercultural competences
  • Ability to operationalize essential health plan functions and map workflows, policies, and procedures to govern and guide staff activities
  • Ability to define staff roles and responsibilities to effectuate health plan objectives
  • Ability to apply common sense understanding to carry out instruction furnished in written, oral or diagram form; deal with problems involving several variables in standardized situations
  • Excellent ability to provide all content within a biblical framework

Core Competencies/Demonstrable Behaviors

  • Collaborates – builds partnerships and works collaboratively with others to meet objectives. This role requires a high level of internal customer interaction to meet objectives
  • Manages Conflict – handles conflict situations effectively.
  • Interpersonal Savvy – relates openly and comfortably with a diverse group of people. Must be able to communicate effectively and build engagement across all audiences
  • Drives Results – consistently achieves results, even under tough circumstances and tight deadlines.
  • Situational Adaptability – adapting approach and demeanor in real time to match the shifting demands of different situations.
  • Courage – ability to have tough conversations and deliver accurate advice and decisions regardless of risk or potential criticism

Education and/or Experience

  • Bachelor’s degree in Nursing, Social Work, Healthcare Management or closely related field with 8+ years’ experience in a healthcare payer organization, or equivalent experience required
  • Master’s or Doctorate degree in Healthcare Administration (MHA), Healthcare Clinical or Operations Management or similar accredited program preferred
  • 5+ years’ previous utilization review and clinical people leadership experience in a healthcare payer organization required
  • Experience in a value-based care organization preferred
  • Experience in Care Management with understanding of population health and risk stratification principles preferred

Supervisory Responsibilities

  • This job has supervisory responsibilities. The Care Management department is comprised of roughly 40 employees that would fall under direct or indirect supervision of this role. 

Incentives & Benefits

We work hard to serve our Medi-Share Members, but know we can only do that if we invest in our employees professionally, financially, physically, socially, and spiritually. We purposefully invest in our employees so that our employees can invest in others.

For full-time employees working 30 hours or more, some of our benefits include, but are not limited to:

  • 100% paid Medical for employees/99% for family
  • Generous employer Health Savings Account (HSA) contributions
  • Employer-paid Life Insurance (3x salary) and Long-term Disability Insurance
  • 6 weeks of paid parental leave (for both mom and dad)
  • Dental - two plans to choose from
  • Vision
  • Short-term Disability
  • Accident, Critical Illness, Hospital Indemnity
  • 401(k) – up to 4% match on ROTH or Traditional contributions
  • Generous paid-time off and 11 paid holidays
  • Wellness plan including Financial, Occupational, Mental/Spiritual, and Physical health incentives up to $50/mo 
  • Employee Assistance Program including no cost, in-person mental health visits and employee discounts
  • Monetary Anniversary Awards Program
  • Monetary Birthday Awards