Director of Utilization Management

Under the general supervision of the Vice President of Clinical Operations for the Detroit Wayne Integrated Health Network (DWIHN), the Director of Utilization Management is responsible for managing the day-to-day operations of the Utilization Management Program and staff. This position oversees all phases of development, organization, planning and implementation of Utilization Management projects, initiatives, work flows and processes to enhance quality-driven outcomes. The Director is expected to monitor activities that include overutilization, underutilization, standardization, implementation of new technology and assurances that DWIHN values are met.  

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Develops and oversees processes and procedures to ensure department-wide compliance with contractual, regulatory (Federal/State) and accreditation entities.   
• Serves on the executive management team and coordinates activities with other department directors to ensure utilization management tasks are integrated with other Department functions.   
• Assists the Chief Medical Officer (CMO) in facilitating the Utilization Management Committee and participates on other DWIHN committees such as Quality Assurance.   
• Works closely with the Chief Medical Officer to ensure timely and accurate reviews that result in medically necessary, appropriate, efficient, and cost-effective services.   
• Monitors and tracks key performance indicators to independently identify over/under utilization patterns and/or deviation from expected results.   
• In collaboration with the CMO and Vice President of Clinical Operations, assists in identifying and then implementing strategies to correct trends of either over or under utilization.
• Oversees Departmental activities including, and not limited to, hospital authorizations and continued stay reviews, Self Determination activities, provider service authorization review and approval, and denial and appeals.
• Facilitates the DWIHN County of Financial Responsibility (COFR) Committee.
• Prepares statistical and narrative utilization management reports for submission to the VP of Clinical Operations on utilization patterns, expenditures by area and revenue stream, demographics of service delivery and trending of expenditures by program.  
• Establishes and amends, as necessary, a reporting system for the Manager of Comprehensive Networks, Direct Service Providers, Substance Use Disorder Providers, and other stakeholders.  
• Oversees UM portion of all readiness reviews (i.e External Quality Review Organization (EQRO) and Michigan Department of Health and Human Services); NCQA.   
• Develops and monitors the budget for the Department while ensuring sufficient resources are assigned to meet the utilization management goals.   
• Serves as the liaison for DWIHN concerning utilization management activities, including participation in external meetings and coordination with external entities.   
• Works with staff to develop clear and concise development plans to ensure the advancement of the utilization management goals.   
• Develops formal department-specific new staff orientation and training programs.   

• Performs related duties as assigned.

   

KNOWLEDGE, SKILLS, AND ABILITIES (KSA's):

Knowledge of DWIHN policies, procedures and practices.

Knowledge of Utilization Management

Knowledge of Quality Assurance.

Knowledge of Federal policies, rules, regulations and procedures as it relates to behavioral health.

Knowledge of Medical Necessity Criteria for Behavioral Health services, American Society of Addiction Medicine Patient Placement Criteria (ASAM) and the Federal Confidentiality