Director, Utilization ManagementAlameda Health System • Oakland, CA, US
Director, Utilization Management
Alameda Health System • Oakland, CA, US
30+ days ago
Job type
- Full-time
Job descriptionUnique benefit offerings that are partially or 100% employer-paid Rich and varied retirement plans and the ability to participate in multiple plans. Generous paid time off plans Lead and manage a team of utilization review professionals providing guidance, training, and performance evaluations. Monitor and evaluate the utilization of healthcare services, including appropriateness, efficiency, and medical necessity of treatments and procedures. Analyze data and generate reports on utilization trends, outcomes and quality indicators to support decision-making and process improvement initiatives. Reports to appropriate committees. Manage quality of performance criteria, policies and procedures, and service standards for the utilization management operations. Evaluate utilization reviews and determine program improvements. Develop and implement utilization review policies and procedures in accordance with industry standards and regulatory requirements. Direct and coordinate data gathering and record keeping legally required by federal and state agencies, the Joint Commission, and hospital policies; participates in the risk mitigation, process of implementing new or revised processes, and projects Foster effective communication and collaboration with internal departments, external agencies, and insurance providers to facilitate the utilization review process. Participate in interdisciplinary committees and meetings to contribute to the development and implementation of quality improvement initiatives. Oversees the secondary review process; actively appeals denied cases when necessary and assists physicians with appeals. Maintains minimal denial rates by Medicare, MediCal, private and contracted payers through appropriate direction of utilization practices; assists physicians and hospital personnel in understanding UM matters. Perform all other duties as assigned. Prepares cost analysis reports and other data needed for the preparation of the departmental budget. Provides in-house educational programs as needed for both staff and physicians. Responsible for the recruitment, orientation, evaluation, counseling and disciplinary action of UM and administrative staff. Serves as a content expert to staff and internal departments and external partners; networks with other hospitals, nursing organizations, and professional organizations to keep abreast of changes within the profession.
Job Description
Summary
\n
\n \n\t
- 100% employer health plan for employees and their eligible dependents
\n\t
\n\t
\n\t
\n \n\n
\n\n
Role Overview : \n\n
Alameda Health System is hiring! The Director of Utilization Management holds a critical role encompassing operational oversight, strategic planning, compliance, and collaboration. Their responsibilities span from managing admissions to ensuring clean claims, identifying trends, and optimizing resource utilization. This role supports patient care coordination, fosters physician collaboration, and aligns with organizational objectives while adapting to ad hoc duties as needed. In essence, they orchestrate efficient utilization management to deliver high-quality patient care.
\n\n
\n\n
DUTIES & ESSENTIAL JOB FUNCTIONS : NOTE : Following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.
\n\n \n\t
\n\t
\n\t
\n\t
\n\t
\n\t
\n\t
\n\t
\n\t
\n\t
\n\t
\n\t
\n\t
\n\t
\n \n\n
MINIMUM QUALIFICATIONS :
\n\n
Required Education : Bachelor’s degree in Nursing
\n\n
Preferred Education : Master’s degree in Nursing
\n\n
Required Experience : Three years of utilization review experience. Health insurance company and / or acute care hospital, post-acute and psych; three years of InterQual and / or MCG. Strong clinical nursing background.
\n\n
Required Licenses / Certifications : Valid license to practice as a Registered Nurse in the State of California.
\n\n
Preferred Licenses / Certifications : UM / CM certifications
\n
\n
Highland General Hospital
SYS Utilization Management
Full Time
Day
Nursing
FTE : 1
Create a job alert for this search
Director Utilization Management • Oakland, CA, US
Related jobs
Supermicro is a Top Tier provider of advanced server, storage, and networking solutions for Data Center, Cloud Computing, Enterprise IT, Hadoop / Big Data, Hyperscale, HPC and IoT / Embedded customers...Show more
A company is looking for a Director, IDD Incident Management and Quality Outcomes, Performance-Based Contracting.Key Responsibilities Oversee the full lifecycle of incident management, ensuring c...Show more A company is looking for a Director of Customer Experience.Key Responsibilities Define key performance metrics and benchmarks for Customer Experience, driving continuous improvement Provide acti...Show more 
Senior Director, PDM Operations Management.At Gilead, we're creating a healthier world for all people.For more than 35 years, we've tackled diseases such as HIV, viral hepatitis, COVID-19 and cance...Show more
At Synopsys, we drive innovations shaping the way people live and connect.Our technologies enable breakthroughs in chip design, verification, and IP integration, powering the future of high-perform...Show more Supermicro is a Top Tier provider of advanced server, storage, and networking solutions for Data Center, Cloud Computing, Enterprise IT, Hadoop / Big Data, Hyperscale, HPC and IoT / Embedded customers...Show more A company is looking for a Utilization Management Technician.Key Responsibilities Coordinate, generate, and track correspondence, faxes, and authorizations related to utilization management Inte...Show more A company is looking for a Director of Account Management.Key Responsibilities Develop and execute account management strategies to drive product adoption and customer retention Lead and mentor ...Show more A company is looking for a Director of Clinical Services Operations.Key Responsibilities Lead day-to-day operations ensuring compliance with contracts and regulations Develop and implement proce...Show more A company is looking for a Director of Product Management - Ambulatory.Key Responsibilities Lead a cross-functional team in developing and executing strategic direction for ambulatory healthcare ...Show more A company is looking for a Lead Director of UM Innovation Delivery.Key Responsibilities Lead and manage strategic projects and programs from initiation to completion, ensuring on-time delivery an...Show more A company is looking for a Director - Technical Program Management.Key Responsibilities Build and lead a team of Technical Program Managers to support dedicated deployments and ensure reliable de...Show more A company is looking for a Lead Director, Program Management.Key Responsibilities Collaborate with clinical and operational leaders to identify business needs and strategic objectives Analyze cu...Show more 
KLA is a global leader in diversified electronics for the semiconductor manufacturing ecosystem.Virtually every electronic device in the world is produced using our technologies.No laptop, smartpho...Show more
Director, Engineering Management - (M6)Santa Clara,CA • •Who We Are • •Applied Materials is a global leader in materials engineering solutions used to produce virtually every new chip and advanced disp...Show more
Director of Revenue Cycle Operations.Midi Health is scaling rapidly, and we’re looking for a seasoned Revenue Cycle leader to partner with our Head of RCM to drive strategy and execution across a f...Show more
Quantum computing holds the promise of humanity's mastery over the natural world, but only if we can build a.PsiQuantum is on a mission to build the first real, useful quantum computers, capable of...Show more
Join us in making the world's first Cognitive ERP!.The Director of Product Management - AI, 0 to 1 will drive the strategic direction and execution of our 0 to 1 efforts in agentic AI for Epicor's ...Show more
Director, Product Management
Supermicro • San Jose, CA, United States
Full-time
Last updated: 30+ days ago • Promoted
Director of Incident Management
VirtualVocations • Hayward, California, United States
Full-time
Last updated: 21 days ago • Promoted
Director of Customer Experience
VirtualVocations • Fremont, California, United States
Full-time
Last updated: 30+ days ago • Promoted
Senior Director, PDM Operations Management - Foster City
Gilead • San Mateo, CA, US
Full-time
Last updated: 30+ days ago • Promoted
Director of Customer Program Management (Strategic Engagements)
Synopsys • Sunnyvale, CA, United States
Full-time
Last updated: 30+ days ago • Promoted
Director, Solution Management
Supermicro • San Jose, CA, United States
Full-time
Last updated: 30+ days ago • Promoted
Utilization Management Technician
VirtualVocations • Concord, California, United States
Full-time
Last updated: 30+ days ago • Promoted
Director of Account Management
VirtualVocations • Hayward, California, United States
Full-time
Last updated: 30+ days ago • Promoted
Director of Clinical Operations
VirtualVocations • Hayward, California, United States
Full-time
Last updated: 30+ days ago • Promoted
Director of Product Management
VirtualVocations • Concord, California, United States
Full-time
Last updated: 30+ days ago • Promoted
Director of UM Innovation
VirtualVocations • Fremont, California, United States
Full-time
Last updated: 3 days ago • Promoted
Technical Program Management Director
VirtualVocations • Hayward, California, United States
Full-time
Last updated: 4 days ago • Promoted
Lead Director of Program Management
VirtualVocations • San Francisco, California, United States
Full-time
Last updated: 4 days ago • Promoted
Director - Identity and Access Management (IAM)
KLA • Milpitas, CA, United States
Full-time
Last updated: 4 days ago • Promoted
Director, Engineering Management - (M6) Santa Clara,CA Engineering Posted a day ago
Nutanix • Santa Clara, CA, United States
Full-time
Last updated: 9 days ago • Promoted
Director, Revenue Cycle Operations
Femtech Insider Ltd. • Menlo Park, CA, United States
Full-time
Last updated: 7 days ago • Promoted
Senior Director, Project Management
PsiQuantum • Palo Alto, CA, United States
Full-time
Last updated: 27 days ago • Promoted
Director of Product Management
Epicor • Dublin, CA, United States
Permanent
Last updated: 7 days ago • Promoted