Director of U.M. Remote

Utilization Management Director

Insight Global is sourcing for a Utilization Management Director to join a not-for-profit community based healthcare organization within the Operations organization. This position will fall within the Clinical Performance, Operations, and Innovation organization. The U.M. Director is responsible for reviewing and providing guidance for authorizations and member profiles at a high volume, roughly 540 cases per month. This role is a key role in helping our organization provide high quality, equitable care to our rapidly growing membership. The incumbent will have significant experience with utilization review, ideally experience with public programming, and excellent clinical judgment. This position is 100% remote but must have active Massachusetts license and MA Health Enrollment. Compensation : $140 / hr. to $160 / hr. Exact compensation may vary based on several factors, including skills, experience, and education. Benefit packages for this role will start on day one of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401K retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and / or other paid time off as provided by applicable law. We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity / affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and / or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to HR@insightglobal.com.

Skills and requirements :

• Active Massachusetts License
• Document case review findings, actions, and outcomes in accordance with Utilization Management policies; meets health plan inter-rater reliability guidelines
• Appropriately access clinical specialty panel physicians to assist in complex or difficult case
• Ensure compliance with medical policy. Maintains compliance with all federal, state, and local regulatory guidelines
• Serve as the lead for CCA's Utilization Review functions working closely with other medical management team members
• Support the development of utilization management policy initiatives
• Support the development and implementation of medical policy, including recommendations for modifications to enhance efficiency and effectiveness
• Experience with Medicare and Medicaid