Director, Medical Management
21 hours ago
Henderson
Director - Medical Management Location: Hybrid, required to be in NV office a couple times a month. Looking for candidates who reside in NV, AZ, OR, or CA Description: The Director, Medical Management is responsible for the strategic leadership, development, and operational oversight of utilization management (UM), clinical review, claims collaboration, and medical management functions across multiple delegated managed care health plan contracts and states. This role ensures alignment between Utilization Management, Case Management, and Claims Operations to drive improved patient experience, provider experience, clinical quality, operational efficiency, and turnaround times. The Director collaborates with senior leadership, health plans, vendors, and internal clinical teams to ensure regulatory compliance, optimize medical cost performance, and enhance the integration of technology, data analytics, and clinical operations. What You Will Do: • Collaborates with senior leadership to establish Medical Management strategic goals, objectives, and performance targets aligned with organizational goals and financial outcomes., • Leads development, implementation, and continuous improvement of Utilization Management programs, workflows, criteria application, and regulatory compliance across all markets., • Ensures alignment and integration between UM, Case Management, Claims, Quality, and Clinical Operations to improve outcomes and member experience., • Oversees prospective, concurrent, and retrospective utilization review processes, ensuring adherence to CMS, State, NCQA, MCG/InterQual, and internal regulatory standards., • Ensures UM reviewers, physicians, and case management partners apply nationally recognized clinical criteria consistently and appropriately., • Monitors UM productivity, turnaround time (TAT), decision accuracy, and quality benchmarks., • Partners with Claims leadership to identify and resolve UM-Claims processing gaps, reduce provider abrasion, and accelerate claims payment accuracy and timeliness., • Works with Claims to review denial reasons, coding patterns, and authorization-to-claim mismatches to reduce rework and appeals., • Implements cross-functional workflows to improve provider communication, prior authorization clarity, and first-pass claims accuracy., • Serves as a clinical resource and operational partner to Case Management and Population Health teams to support transitions of care, discharge planning, and complex case reviews., • Collaborates with network providers, hospitals, and health plan partners to improve care coordination, reduce unnecessary admissions, and optimize care pathways., • Ensures consistent application of clinical and operational guidelines across the care continuum., • Leads oversight and auditing of delegated vendors and subdelegates to ensure compliance, workflow accuracy, and performance impact on key indicators., • Oversees delegated medical management contract requirements and health plan partnership expectations., • Leads preparation for CMS, State, and health plan audits and serves as the primary point for survey readiness and corrective action planning., • Uses advanced data analytics to monitor utilization trends, medical cost drivers, high-variance providers, and performance by service category., • Collaborates with reporting teams and system developers to design dashboards and reporting tools that improve transparency, performance tracking, and decision-making., • Ensures all required internal and health plan reports are timely, accurate, compliant, and actionable., • Provides education to internal teams, providers, and external partners on guidelines, clinical criteria, workflows, and compliance requirements., • Builds strong relationships across departments to strengthen collaboration and operational efficiency., • Represents the Medical Management department to health plans, providers, and community partners. You Will Be Successful If: • Expert-level knowledge of Utilization Management processes, nationally recognized criteria (MCG, InterQual), CMS and State regulations, and medical management best practices., • Strong understanding of clinical workflows, care transitions, and evidence-based guidelines., • Ability to interpret clinical documentation, evaluate medical necessity, and guide clinical decision-making., • Strong knowledge of Claims processing, adjudication workflows, authorization-to-claim matching, and denial/reconsideration processes., • Ability to partner with Claims to improve first-pass accuracy, reduce rework, and streamline provider payment processes., • Advanced experience with analytics, reporting tools, and interpretation of complex data sets., • Ability to collaborate with developers, reporting engineers, and business intelligence teams to create dashboards and operational monitoring tools., • Ability to learn and manage internal and third-party medical management systems., • Ability to work independently under minimal direction while providing strong leadership to large teams., • Strong vendor management and auditing skills., • Excellent written and verbal communication skills, including ability to engage executive leaders, clinicians, and health plan partners., • Strong ability to build cross-functional relationships at all organizational levels. What You Will Bring: • Bachelor’s degree in nursing, required. Master's degree, preferred., • Unrestricted nursing license in NV, AZ, CA, or OR and ability to obtain licensure in all states as needed., • 5+ years of clinical nursing experience, including a minimum of three years in a managed care/HMO organization, required., • 2+ years managerial experience over a managed care, medical management system required., • Experience with State and external accreditation, managed care audits and reviews required., • Experience in utilization management program set up, policy and procedure development for efficient programs, understanding of nationally recognized standards and guidelines (CMS, NCQA, MCG, etc.)., • Experience managing vendors., • Experience with concurrent review and CMS guidelines for inpatient, skilled nursing facility, and acute inpatient rehab admissions and continued stays., • Experience with policy and procedure writing., • Experience applying medical management treatment guidelines and nationally recognized criteria, such as InterQual / McKesson, MCG, or other practical management guidelines required., • Experience leading health plan audits and conducting sub-delegation audits., • Experience with ODAG reporting, monitoring turn around time, staff productivity, and adherence to guidelines., • Experience with State and external accreditation, managed care audits and reviews required. About Impresiv Health: Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges. Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it. That’s Impresiv!