Director, Inpatient UM

About the role

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We've had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it's at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health . Job Summary The Director, Inpatient Utilization Management is responsible for directing, leading, and modifying the business processes and operations for utilization management (UM) review tor is responsible for ensuring achievement of Point32Health corporate goals; compliance with Point32Health business rules; oversight of all aspects of outpatient services utilization management; and development, implementation and refinement of effective business processes that support compliance with relevant regulatory requirements (such as CMS, DOI, NCQA, ACA, USFHP and/or ASO/ERISA). The Director is expected to strategically develop and effectively deploy solutions in support of corporate and division specific goals. She/he will do so in an engaged and professional manner within and through a matrixed business environment. The Director will collaborate with division and enterprise business and medical leadership to drive clinical and/or operational initiatives. The Director is expected to collaborate with other Health Care Services peers / leaders, Operations and/or divisional department clinical leaders (such as the divisional CMO, Medical Directors, Directors and/or business leads), plan medical staff and key provider - facility and physician or group - clinical leadership. The Director oversees and leads medical management activities related to utilization management and discharge planning for acute inpatient, LTAC (Long-term Acute Care) rehabilitation and skilled nursing services. The Director ensures initiatives are on schedule and within budget, and guides strategy, policies, and protocols in accordance with organizational strategy. The Director will ensure collaboration and coordination with enterprise or divisional based behavioral health and / or case management leaders and programs. The Director assumes a leadership role with internal and external customers to achieve optimal clinical and resource outcomes. Job Description Key Responsibilities/Duties oversee and lead the precertification management and related authorization management operations for Commercial, Senior and Public Plans (MassHealth and QHP (Qualified Health Plan)) products. Effectively collaborates with divisional Chief Medical Officers, enterprise Medical Directors, enterprise, and division based Behavioral Health leaders to support appropriate utilization of health care services and quality of care for all products. Lead or support medical trend management initiatives in partnership with senior leaders for Health Care Services, Commercial and Government Market divisions. Develop, implement, and oversee business processes to ensure compliance with all federal and state regulatory and accreditation requirements and Point32Health business rules. Ensure that appropriate key performance and outcomes measures are in place, monitored and utilized for program assessment and program management. Oversee and lead effective relationships development between Point32Health and the facility / provider community. Actively participate in and/or lead workgroups and steering committees to identify, plan and implement Point32Health strategic expansion initiatives, utilization management, and/or clinical operations strategies. Represent Point32Health and Health Care Services to internal and external clients regarding clinical operations, utilization management, complex or unique client systems being designed or revised, and program performance for client specific SLAs (service level agreements) / KPIs (key performance indicators). Recruit, hire, educate, and evaluate staff. Guide and enhance the professional development of reporting staff. Provide coaching, feedback, and direction to ensure the successful achievement of business and professional goals. Support effective operational techniques while promoting customer satisfaction and operational efficiency in all areas of accountability. Plan budget and oversee management of department resources. Participate as a key member in th