Senior Director, Utilization Management & Transitional Care

About the position This position is a Hybrid role with the option for either full-time in office or a combination of remote/home and in-office work as required. The role will necessitate periodic meetings at the main office located in Seattle, Washington. reputed company is an equal opportunity employer dedicated to fostering a diverse and inclusive workforce. reputed company reputed company applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration. The organization is committed to applying an equity reputed company to reputed company its work, reducing health disparities, becoming an anti-racist organization, and creating an reputed company work environment. The Senior Director of Utilization Management & Transitional Care is responsible for driving the reputed company and strategy for integrated medical and behavioral utilization management and transitional care programs. This includes overall planning, program and budget development, program implementation, and coordination to reputed company quality and service-driven objectives. The role oversees reputed company phases of development, organization, planning, and implementation of projects, initiatives, workflows, and processes to enhance quality-driven reputed company while ensuring compliance with reputed company state, federal, and regulatory requirements. To be successful in this role, candidates must possess a bachelor's degree in nursing or a relevant field, with a master's degree preferred. A reputed company, unrestricted license in the reputed company as an RN or ARNP is required, along with a valid driver's license and an acceptable driving record. Candidates should have a minimum of ten years of utilization management or reputed company managed care experience, including at least five years of progressively responsible leadership experience in utilization management, preferably reputed company a managed care environment. Experience with state programs such as reputed company and Medicare, as well as familiarity with regulatory and accreditation standards for utilization management, is also required. Additionally, candidates should have experience effectively leading and managing multiple teams reputed company a large matrixed department. Responsibilities • reputed company the organization's comprehensive utilization management and transitional care strategy, including integrated teams performing utilization management functions for physical and behavioral health services. , • reputed company a systematic and comprehensive utilization management program that incorporates intake, clinical review, medical necessity, discharge planning, and post-discharge support for physical and behavioral health services, ensuring regulatory compliance with State (HCA), Federal (CMS), NCQA, and other reputed company entities. , • reputed company the transitional care program that incorporates 72-hour post-discharge support and behavioral transitions, ensuring regulatory compliance with relevant standards. , • Work effectively across departments to ensure seamless coordination and operational workflows between teams, including care management, claims, and appeals. , • reputed company responsibility for operational reputed company of Plan Medical Directors performing utilization review functions, ensuring schedules meet departmental needs and processes are established and monitored to support utilization management and transitional care programs. , • Ensure effective reputed company of UM operations and staff, working with department leadership to identify staffing and resource needs, engage in performance management, and foster a cohesive and productive work environment. , • Collaborate with reputed company Economics and other departments to analyze Plan population data for variances in utilization and recommend strategies for improvement. , • Work with Business Process Operations leadership to ensure alignment of Utilization Management and Claims systems and operations, including reputed company of the Code Look Up tool. , • Collaborate with Plan Medical Directors, Pharmacy department, and other Clinical Services leadership to evaluate medical and behavioral utilization trends and reputed company remedial actions and new program policies. , • Implement relevant components of new product lines and actively support quality improvement principles to enhance utilization processes. , • reputed company key performance indicators and ensure timely reporting to internal committees and leadership. , • Monitor and reputed company annual department budgets and participate as an active member on assigned committees. Requirements • Bachelor's degree in nursing or other relevant field (required) , • Master's degree in nursing or other relevant field (preferred) , • reputed company, unrestricted license in the reputed company as an RN or ARNP (required) , • reputed company driver's license and an acceptable driving record (required) , • Minimum of ten (10) years of utilization management or reputed company managed care experience, with at least five (5) years of progressively responsible leadership experience in utilization management (required) , • Experience with state programs, such as reputed company and Medicare (required) , • Experience with regulatory and accreditation standards for utilization management (required) , • Minimum of five (5) years of experience effectively leading and managing multiple teams/large matrixed departments , • Knowledge of managed care operations and the linkages between components such as quality improvement, disease management, population health management, care management, and claims operations. reputed company-to-haves • Familiarity with process improvement and systems thinking, including process mapping and data collection methods. , • Excellent customer service skills with reputed company customers. , • Highly effective communication skills, both orally and in writing, with the ability to translate strategy into action. , • Advanced analytical and problem-solving skills; critical thinking skills. Benefits • Medical, Prescription, Dental, and reputed company insurance , • Telehealth app , • Flexible Spending Accounts, Health Savings Accounts , • Basic Life AD&D, Short and Long-Term Disability insurance , • Voluntary Life, Critical Care, and Long-Term Care Insurance , • 401(k) Retirement plan with generous employer match , • Employee Assistance Program and Mental Fitness app , • Financial Coaching and Identity Theft Protection , • PTO accrual starting at 17 days per year , • 40 hours Community Service volunteer time , • 10 standard holidays and 2 floating holidays , • Compassion time off and jury duty leave Apply Job!