Evolent Health is looking for a locally based, focused Manager of Utilization Management to partner with the Utilization Management clinical operations team to serve the Dayton, Ohio based operations for the Premier Health Group. The Market Manager, Utilization Management oversees daily utilization management and directs the medical care of our members on behalf of our clients and serves in a supporting role to the Managing Director of Utilization Management. The Market Manager is accountable for and provides professional, local leadership and direction to the utilization/cost management and clinical quality management functions. Works collaboratively with the Associate and Market Medical directors as well as the other medical management stake holders such as provider relations, quality management, compliance, member services, benefits and claims management. Assists (as determined by Managing Director of UM) in ensuring that daily utilization management occurs, managing the client specific UM work plan; short and long range program planning; total quality management (quality improvement) and client relationships. Works with Clinical Delivery and Operations leadership to support, and provide assistance and direction in overall medical management effectiveness. Monitors all issues of operational UM functions and metrics within in the confines of the quality oversight policies and procedures. Manages the functions that support NCQA accreditation at a local and/or client level. Collaborates with Evolent’s Associate and Market Medical directors around evidence-based practices and medical policies under the guidelines of Evolent’s medical policies.
- Responsible and accountable to the Managing Director, Utilization Management to monitor the utilization management of resources of the local client network and implementation of initiatives and educational processes to achieve targeted utilization management results established by the client.
- Responsible for hiring, onboarding and directing local, market focused utilization management staff.
- Responsible for monitoring staffing ratios and identifying the need for growth of the utilization management team to support membership growth and client requirements.
- Develops local systems and aligns with Evolent processes for the assumption of utilization management responsibilities by the provider network to create alignment and accountability
- Responsible for monitor and driving improvement of utilization management metrics over client baseline.
- Responsible for monitoring, driving, and quality improving daily utilization management work flows managed directly or indirectly on behalf of the client.
- Monitoring the timeliness and accuracy of utilization management data and reporting to meet requirements of applicable regulatory agencies.
- Implement and manage the utilization management work plan to meet monthly, quarterly and annual deliverables as per client contract, local, and federal regulatory requirements.
- Development and implementation of appropriate utilization management programs, policies, and process improvements.
- Responsible for ensuring rigorous, consistent, and disciplined design and execution of integration with the Evolent Health Quality Management program.
- Using data analysis to identify opportunities for quality improvement.
- Developing and adopting best practice methodologies and training programs for utilization management tools and techniques.
- Responsible for directing activities related to special projects for utilization management and use of project resources.
- Management of local budget, staffing plans, and assuring adequate allocation of resources.
- Assisting to build local utilization management initiatives and tools to support Evolent Health and the local client.
- Responsible for contributing to development of business requirements in collaboration with the IT and analytics teams for the development of required utilization management monitoring, predictive modeling initiatives, patient engagement and other outcomes initiatives relevant to utilization management.
- Enhancing relationships with providers, facilities, plan sponsors, clients, regulatory agencies, and partners.
- Responsible for monitoring market member and provider satisfaction survey results and creating necessary changes where indicated.
- Working collaboratively with other functional areas that interface with the utilization management department including provider services, member services, benefits, claims management, contracting, and healthcare and medical delivery services.
- Responsible for providing appropriate, timely management of complex clinical issues.
- Mentoring employees and supporting ongoing training and development of staff.
- Promoting a positive work environment by providing timely, specific and constructive performance feedback.
- Bachelor’s Degree in Nursing with active Ohio nursing license (Masters in Nursing, Business Administration/Hospital Administration/ Public Health a plus).
- 5-8 years of operations and Utilization Management experience in a population management or managed care/insurance or hospital medical management department setting.
- Sophisticated knowledge of clinical operations in managed care, including quality management, outcomes, provider network, claims, financial management, care management policies, disease state and population management, members’ rights and responsibilities, and ability to quickly assess client practices.
- Experience in consulting or services organizations with a proven ability to manage client relationships and achieve change within another organization.
- Responsible for driving and achieving a high standard of quality utilization management and results.
- Working knowledge of clinical quality metrics such as HEDIS, NCQA and National Quality Forum metrics.
- Entrepreneurial mindset geared toward the creation, execution and continuous improvement of a utilization management program from the ground up.
- Ability to work in a fast paced, team environment with sensitivity toward client needs and critical deadlines.
- Intellectual curiosity and an ability to view old problems with a fresh perspective.
- Ability to understand the workflow of the multiple components of the company and client, and to assist in the creation and implementation of integrated policies, procedures, work plans and creative solutions.
- Responsive to deadlines and has work completed on or before deadline 100% of the time.
- Ability to attract, manage and develop staff of superlative quality
- Excellent written computer and oral communication skills. Consistently completes continuing education activities relevant to maintaining active clinical licensure in one or more states.
Knowledge and Skills:
- Management skills to meet the organizational goal.
- Must possess excellent communications skills to interface with providers, staff, and management.
- Knowledge of medical, quality improvement and utilization management practices in a managed care environment.
- Knowledge of regulatory and accreditation agencies and requirements.
- Able to manage multiple priorities and deadlines in an expedient and decisive manner.
- Appreciation of cultural diversity and sensitivity towards target population.
- Ability to navigate in a corporate matrix environment.
Evolent Health supports progressive health care systems lead, build and own the path to value-based care. Evolent is a high-growth, entrepreneurial company founded in 2011. We are backed by established players in the health care industry: The Advisory Board Company (NASDAQ: ABCO), University of Pittsburgh Medical Center Health Plan, the nation’s second largest provider-owned plan, and TPG Growth, part of an investment firm with $55.3 billion of assets under management. Our investor partners contribute proven population health expertise, intellectual property, and strong financial backing to propel our leadership in the market. Evolent integrates the people, processes and technology needed to advance value-based care delivery and innovative payment models.
Selected as one of Modern Healthcare’s Best Places to Work, Evolent provides an opportunity to work with top experts in the health care field in an organization committed to career development. Our rapid growth is made possible by a team of professionals who thrive in a dynamic, fast-paced environment. While our team comes from a variety of backgrounds, we share a passion to advance health and health care, and a desire to pursue our passion in an innovative setting.
Our accessible leadership team cultivates an open door environment. We don’t like approval chains; we love ideas and people with the courage and conviction to bring novel solutions forward. We win as a team and always ask how we can do better. We respect and encourage commitments outside of work. While we don’t all work the same way or the same hours, we are all dedicated to exceptional results.
Our Work Environment
Headquartered near Washington, DC in Arlington, Virginia, we have additional sites in San Francisco, Pittsburgh and in client markets across the country. Our open workspace is specifically designed for collaboration and efficiency. Walking treadmill desks, an onsite fitness center, healthy snacks and fitness challenges are a part of our expansive wellness program. Evolent also sponsors company-wide community service projects and supports individual volunteering.
Our Compensation and Benefits
We recognize and reward our most valuable asset—our team—with competitive pay and annual performance-based bonuses. Evolent also offers comprehensive health benefits, a company-matched 401(k) beginning day one and flexible spending accounts for daycare and transit. Each employee receives 25 personal days and 10 holiday paid days off each year.
An Equal Opportunity Employer