Job Summary

The Director of Behavioral Health Utilization Management and Case Management department is responsible for assisting in the development and implementation for operational and functional support for Behavioral Health Utilization Management and Case management activities. This position (1) directs and coordinates the operations of all behavioral health activities to ensure compliance with policy and procedures, accreditation, and regulatory standards; (2) provides direction to Information Services development/management; (3) provides direction in regards to the impact on the behavioral health department to
the appropriate departments to support the development and launching of new programs; (4) collaborates with clients and account management to deliver quality products and provide excellent customer services; (5) assists product development/management, marketing and sales with the development of product collateral and RFP responses; (6) participates in presentations for prospective clients and existing clients (7) oversees the management responsible for managing all behavioral health inbound and outbound call center functions to meet performance and quality standards; (8) oversees the management responsible for managing productivity, timeliness and quality for all behavioral health authorization requests; (9) oversees the management responsible behavioral health productivity, timeliness and quality of case management activities; (10) Responsible for adhering to budgetary constraints and effectively utilizing resources to manage the day to day operations of the
behavioral health department. (11) works in collaboration with the Behavioral Health Medical Director and the Executive Vice President of Customer Delivery to track and trend under and over utilization of behavioral health services, to identify opportunities for improvement, followed by implementation of policies and procedures to initiate and monitor the impact the behavioral health utilization management and case management activities; (12) collaborates with the Vice President of Operations to ensure that the complete process for the behavioral health authorizations process from start to finish entering of demographics, obtaining and processing clinical information, through the physician review process, for the cases that are reviewed by a physician, meets timeliness standards; (13) collaborates with the Vice President of Synergy and the Director of Medical
Management to coordinate care for members who have access to all of our programs.

Minimum Qualifications
Education/License/Certification

Licensed clinician with a current, unrestricted license required.
Additional certification in area of specialty and/or case management preferred. Bachelor’s or Master’s Degree preferred.

Experience

Minimum of 5 years experience in Utilization Management, with Behavioral Health and Medical UM experience preferred. Minimum 3 years managed care experience and Call Center Management experience preferred, with application of criteria systems and programs, e.g. InterQual or Behavioral criteria.

Knowledge/Skills

• Ability to develop and execute product plans, including identification of resources and budget required.
• Excellent communication skills, both verbal and written;
• Ability to direct and coordinate programs, projects, resources, and staff across multiple company functions.
• Strong analytic qualities to analyze goals, products, programs, and processes and make recommendations for changes.
• Knowledge of managed care, utilization management, case management, and disease management.
• Organizational and project management skills.
• Experience working with clinical documentation programs designed for utilization management programs.
• Personal computer skills in Windows, WORD, EXCEL, Access,
• PowerPoint, and clinical documentation.
• Ability to manage all inbound and outbound call center functions to meet established productivity, performance, and quality standards.
• Strong communication, interpersonal and leadership skills.
• Call center knowledge desirable.

Accountabilities
Job Performance/Responsibilities

• Coordinates and directs all Behavioral Health Utilization Management and CM
• Assure job descriptions and staff roles/responsibilities are accurate and current;
• Supervise the interviewing and hiring of staff and supervisors for the above programs;
• Assist in the licensing and accreditation process for all programs;
• Assure that all regulatory and accreditation standards are implemented and met;
• Assure that Policies & Procedures, Operational Guidelines, and process workflows are current meet quality accreditation and regulatory standards, and are communicated to and available for staff on the Intranet;
• Develop annual Work plan & Summary for each program in conjunction with the QI committee (includes goals, objectives, and planned new processes/enhancements) and communicates the Annual Work plan and previous year’s Summary to Management and staff;
• Assist the Quality department in the development of an annual QI plan for all programs and assures all indicators are met;
• Participate in the Quality Committee and assists in related functions;
• Analyze all programs to ensure effectiveness, quality, productivity, and profitability and patient safety;
• Coordinate all programs and work with other Health Integrated Departments and Committees, i.e. Quality Committee, Education, Account Management, etc;
• Assist in new product development efforts and assures current products are being delivered as designed;
• Assist the VP of Synthesis Operations in plans for growth;
• Provide input and direction to Information Services on systems issues and enhancements;
• Offer input and assist with development of education and training programs;
• Assure delivery expectations of client contracts are being met;
• Assist in the development of management reporting capabilities and works with supervisors to ensure they understand and use them to effectively manage the delivery of services; and
• Provide required reports and special projects as needed.
• Readily available to answer questions and shall ensure non-clinical administrative staff is performing within the scope of the non-clinical role.
• Works directly with the Medical Director on program delivery

Customer Services-Internal

• Work with supervisors and staff to develop a high level of morale and commitment in the work environment;
• Provide strong leadership role model for supervisors and staff;
• Identify problems, issues and/or concerns proactively or as they arise and resolves them as quickly as possible;
• Develop strong working relationships with all internal staff members to encourage a cooperative sharing of ideas and support;
• Monitor and report any quality of care issues or concerns to Quality Management;
• Maintain a courteous and professional attitude when working with all staff members and the management team; and
• Actively participate in team meetings.

Customer Service-External

• Work, communicate and collaborate in harmony and in a courteous and professional manner with members, practitioners, providers, multidisciplinary health care team members, and clients.
• Work collaboratively with the health plan’s management team to assure quality service delivery that meets client expectations. and
• Serve as a liaison and patient advocate, when applicable, for quality of care and cost outcomes