Senior Vice President-Utilization Mgmt (Hybrid, North Carolina Based)

The Senior Vice President of Utilization Management (UM) oversees the Utilization Management department of the BH/IDD Tailored Plan, related to service lines including Physical Health (PH), Behavioral Health (BH) and Long-Term Support (LTSS) services. The position is responsible for overseeing a core component of the BH/IDD Tailored Plan that ensures that individuals receive the correct level and intensity of services that results in positive outcomes.  

This position will allow the successful candidate to work a schedule that will be primarily remote and will report to Morrisville, NC as needed. There is no expectation of being in the office routinely. This position will require travel within the communities Alliance serves as needed. 

Responsibilities & Duties

Manage and Develop Staff

• Work with Human Resources and Directors to attract, maintain, and retain a highly qualified and well-trained workforce
• Ensure proper and adequate staffing for the Utilization Management Department.
• Ensure staff are well trained in and comply with all organization and department policies, procedures, and business processes
• Organize workflows and ensure staff understand their roles and responsibilities
• Ensure the department has the needed tools and resources to achieve organizational goals and to support employees and ensure compliance with licensure, regulatory, and accreditation requirements
• Actively establish and promote a positive, diverse, and inclusive working environment that builds trust 
• Ensure all staff are treated with respect and dignity
• Ensure standards are transparent and applied consistently, impartially, and ethically over time and across all staff members
• Work to resolve conflicts and disputes, ensuring that all participants are given a voice
• Set goals for performance and deadlines in line with organization goals and vision
• Effectively communicate feedback and provide ongoing coaching and mentoring to staff and support a learning environment to advance team skills and professional development
• Cultivate and encourage efforts to expand cross-team collaboration and partnership

Develop Departmental goals and objectives

• In conjunction with Executive Leadership, collaborate in the development of benefit plans that support the delivery of covered service consistent with industry standard, evidenced-based, and best practices
• Engage in strategic planning and implementation activities to respond to and prepare for changes in the healthcare environment
• Develop departmental short-term and long-term strategic plans required for ongoing growth and success
• Use data and analytics to inform decisions about what current strategies are producing value for the member, provider, and Alliance

Oversee department/unit operations

• Oversee a system to maintain and assure that the authorization of services provided by clinical care staff appropriately address the service needs, types of service, outcomes, and alternatives available to consumers
• Oversee administration of the UM Department core functions
• Work with Alliance’s legal, Compliance and Operations Division to ensure the department operates in compliance with Accrediting Body procedures, proactively identify agency risk and implement corrective action when needed
• Implement and monitor systems to detect patterns of over and under utilization and implements corrective plans.
• Ensure that all UM functions are successfully implemented including, but not limited to: system planning; decision making at the policy and practice levels; individual and family involvement; orientation and training of key stakeholders; cultural competence; developing a comprehensive service array; and establishing community capacity and meaningful partnerships
• Develop systems to ensure departmental Key Performance Indicators (KPIs) are met and implement and monitor corrective actions when these are not met
• Ensure compliance with UM performance measures outlined within NC Medicaid and NC DHHS contracts and all Accrediting body standards
• Protect client rights by ensuring all UM staff are trained and follow due process procedures, including the timely processing of treatment requests

Oversee Departmental Budget

• Ensure departmental expenses remain within established annual budget
• Monitor Alliance and departmental spending trends and the effect on the availability of fiscal resources; discuss budget requirements and amendments with Chief Medical Officer

Develop Policies, Procedures, Processes, and Workflows

• Develop and implement department policies and procedures
• Oversee design and implementation of protocols for handling the review of services when pre-treatment authorization is not initially obtained
• Refine and evaluate the methods of authorization for services and treatment; develop strategies for accessing alternative to care

Communicate with Internal and External Stakeholders 

• Communicate and report effectively with leadership at Alliance, providers, community, staff, and stakeholders as needed about service trends, identified gaps and needs, recommended implementation of new processes, practices, and effectiveness of clinical model
• Provide education to hospitals, nursing homes and other care providers concerning departmental procedures and requirements for approving length of stay extensions
• Represent the organization at meetings and conferences with local and state groups

Collaboration

• Collaborate and coordinate with executive leadership to ensure effective operations of the Clinical Operations division, and ensure intra-departmental cooperation on cross department initiatives
• Integrate the department and its functions into the organization’s primary mission
• Collaborate to reach a shared vision of clinical service operations and align the development of function and respective resources with organization growth opportunities
• Identify opportunities for  collaboration on inter-departmental projects that reduces duplication and inefficiencies across the system.
• Maintain accessible and close working relationships with all applicable department heads and decision makers to develop a more coordinated and streamlined service delivery system for individuals and families throughout the service area
• Co-chair the Utilization Management Committee

Monitor vendors

• Oversee and monitor performance standards as outlined in Statement of Work (SOW) for vendors delegated to perform Utilization Management functions

Minimum Requirements

Education & Experience

Master’s degree in Psychology, Social Work, Counseling or related field from an accredited institution with a minimum of ten (10) years of demonstrated care management/population health experience in a healthcare organization (health plan experience preferred) serving Medicaid beneficiaries, including experience with BH and I/DD populations (health plan experience preferred)

Or

Bachelor’s degree in nursing or healthcare and ten (10) years of experience with the population served (health plan experience preferred) 

Five or more years of progressive experience in senior level leadership is required. 

Special Requirement

Current and active North Carolina clinical license, as a LCSW, LMFT, LCMHC, RN (or NC accepted compact license), Licensed Psychologist (LP), MD, or DO is required OR candidates having the ability to successfully obtain a NC license.

Knowledge, Skills, & Abilities

• Comprehensive knowledge of healthcare managed care principles and strategies
• Comprehensive knowledge of Diagnostic Treatment Guidelines/Protocols
• Comprehensive knowledge of Levels of Care Criteria
• Comprehensive knowledge of Care authorization/re-authorization standards
• Comprehensive knowledge of Utilization Management standards
• Excellent Communication skills
• Mediation skills
• Microsoft Office skills
• Leadership and Mentoring skills
• ability to analyze data and develop corresponding strategies
• ability to develop and document workflows
• Ability to analyze effectiveness of processes and make adjustments to developed processes.

Salary Range

$117,532.03 to $202,328.35/annually 

Exact compensation will be determined based on the candidate’s education, experience, external market data and consideration of internal equity.

An excellent fringe benefit package accompanies the salary, which includes:

• Medical, Dental, Vision, Life, Short and Long and Term Disability
• Generous retirement savings plan
• Flexible work schedules including hybrid/remote options
• Paid time off including vacation, sick leave, holiday, management leave
• Dress flexibility

Education

Preferred

• Masters or better in Human Services
• Bachelors or better in Nursing

Licenses & Certifications

Preferred

• Lic Clinical MH Counselor
• Lic Clinical Social Wkr
• Lic Marr & Family Ther
• Lic Psychologist (LP)
• Registered Nurse

Skills

Required

• Communication
• Leadership
• Mediating
• Mentoring
• Microsoft Office