Program Director, Utilization Management
CHRISTUS System Office
CHRISTUS Health Corp Services-68700
919 Hidden Ridge Dr.
Irving, TX 75038
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The Program Director for Utilization Management reports to the System Director, Care Management and, in partnership with CHRISTUS Health leaders, is responsible for the delivery of strategies focused on improving utilization management operations across the health system. The incumbent will do so by evaluating, planning, and implementing tactics focused on successful utilization review functionality. He or she will be responsible for establishing working relationships with internal and external partners to effectively lead performance of utilization review functions. Tracking of process and outcomes metrics will be imperative to this work with anticipated improvements in quality, cost efficiency, and patient care.
- Assist in the assessment, development, implementation, and oversight of best practice Utilization Review (UR) functions across all ministries.
- Implements a high-reliability approach to reduce wasteful variation in practice and eliminates the consumption of unnecessary clinical resources while improving clinical and financial outcomes across the care continuum.
- Develop and implement actions to optimize resources including people, criteria sets, physician advisors, data/analytics, etc. to fullest potential for improved UR outcomes.
- Develop and implement strategy for consistent use of data to drive performance.
- Develop and implement onboarding and ongoing UR RN education strategy and serve as an educator and education resource for all ministries.
- Serve as the system administrator for UR applications such as Milliman Care Guidelines (MCG), American Case Management Association (ACMA) Compass, etc.
- Establish and maintain positive working relationships and practices with physician advisor partners.
- Ongoing evaluation of metrics and processes for early identification of opportunities for improvement and development of tactics to address opportunities.
- Provides swift attention to planning and action based on impactful changes in the market, regulations, managed care contracting, etc.
- Establishes and maintains a collaborative relationship with revenue cycle and managed care teams to enhance effectiveness and improve outcomes
- Provides insight, develops, and implements plans to minimize clinical denials by working collaboratively with key partners in the system office, regions, and health system
- Conducts activities in compliance with state and federal regulations.
- Bachelor's Degree in nursing required
- Master's in Nursing or Healthcare related field preferred
- Minimum of 5 years of utilization review experience
- 3 years of case management/utilization review leadership experience
- Demonstration of experience in a large complex healthcare system, serving multi-disciplinary customers preferred
- Registered Nurse license required
- ACM or CCM certification preferred