Operations

• Directs the utilization management team to ensure the appropriate application of policy procedures and processes to help support best member outcomes
• Oversees and manages Utilization Operations specific to the daily operations of Utilization Management including timeliness, quality and performance outcomes, provider interactions and experience and associated regulatory and/or compliance measures
• Provides strategic leadership and oversight for all non-clinical activities including peer-to-peer requests, authorization entry, and discharge data management
• Leads utilization management team on performance, improvement, and career growth path considerations
• Leads utilization management team policies and procedures to ensure compliance with corporate, state, and National Committee for Quality Assurance (NCQA) standards
• Reviews, analyzes, and reports on utilization trends, patterns, and impacts to deliver an effective utilization program
• Leads process improvements for the utilization management team to achieve cost-effective healthcare results and presents to senior leadership team
• Establishes policies and procedures that incorporate best practices and ensure effective utilization reviews of members
• Develops utilization management strategies and influences decisions by providing recommendations that align to organizational objectives
• Responsible for components of the department’s budget while collaborating inter-departmentally with senior leadership
• Executes the overall strategy for onboarding, hiring, and training new utilization management team members to ensure adequate training and high quality-care to improve member and provider experience and ensure compliance
• Leads and champions change within scope of responsibility
• Provide strategic and operational leadership for the Peer-to-Peer (P2P) Call Center, ensuring timely, accurate scheduling and communication with providers and internal clinical teams
• Develop and monitor service level agreements (SLAs) and key performance metrics for call center operations and case triage performance
• Monitor queue volumes and workforce capacity, adjusting staffing and workflows to meet operational demands

Director, Utilization Management Support Operations

Sales Compensation & Operations Consultant

Global Director – Grid Services Operations

Global Director – Grid Services Operations

Operations Analyst

Operations Specialist