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AVP Care Management and Utilization Review

You may view the full job description and apply on Intermountain Health/Select Health's website here:

https://imh.wd5.myworkdayjobs.com/IntermountainCareers/job/SelectHealth---Murray/AVP-Care-Management-and-Utilization-Review_R112479

The Healthy Connections (Care Management and Utilization Review) AVP at Select Health oversees development and evaluation of utilization and care management, including technology platforms, that support population health management and other mission and objectives of Intermountain Health and Select Health. This position provides strategic and operational leadership in the development, implementation, evaluation, and innovative management of Select Health's Health Services care management and utilization management programs. Programs include but are not limited to acute, complex medical and social, behavioral health and care coordination programs across the entire continuum of care. Responsible for oversight and auditing of delegated functions to other systems or vendors to ensure that all regulatory, accreditation and contracting requirements are being met.
This position is based in Murray, Utah (Salt Lake City metropolitan area) and will require regular in-office time.

Scope:

This position reports to the Chief Medical Officer of Select Health and is a key system-leadership role. Health Services utilization and care management programs impact the medical management of more than $5 billion of revenue across all government, commercial and self-funded product lines of business for more than 940,000 members in multiple states with leadership interface and collaboration across the enterprise. This position oversees a department with 12 direct reports- including 5 managers that oversee approximately 200 FTEs. Emphasis on managing predictive modeling and other digital platform products to both target and scale operations for utilization management, care management (e.g. Care Affiliate strategy, digital outreach, Decision Point enhancements). Oversees vendor/contract management and audits of delegated entities for care management and utilization management across multiple states. Engages with strategic partnerships across the enterprise and with other partners (St. Luke’s, IH NV, UHC PPO, 7day FU with Intermountain Behavioral Clinical program, Castell, Disease Management across the enterprise – like CKD, Oncology, Falls prevention, etc.)

Leads the development of standardized models of care for Medicaid with Integrated Mental Health and A Dual Eligible MOC that meets CMS standards for the development of a D-SNP product. The position will need to have oversight of the care management for these products.

Essential Job Duties:

Stays abreast of industry trends and evaluates utilization, clinical and social determinates of health data to ensure SelectHealth offers competitive programs.
Makes recommendations for innovative programs such as risk stratification, predictive modeling or new models of care for unique population segments.
Participates in the strategic planning process by collaborating in the development of creative system-wide clinical programs, system-wide utilization and continuum of care programs and processes with Intermountain and other strategic partners.
Develops structures and processes to facilitate care coordination among treating physicians, pharmacists, behavior health professionals, and other treating providers in multidisciplinary care planning and care delivery.
Establishes standards for staffing and case load management and guides leadership team to assure standards for key quality indicators, documentation, policies and procedures are met according to Select Health, regulatory and accreditation standards such as CMS, NCQA and EQRO.
Represents Select Health and its Chief Medical Officer in selected meetings and venues, including customer facing finalist presentations and other key customer meetings.

Minimum Qualifications

Hold and maintain a clinical specialty license such as Registered Nurse, LCSW, Nurse Practitioner, Physician's Assistant, Physical or Occupational Therapy. Education and licensure is verified.
Progressive management experience in a managed care environment including organizational and program development skills.
Demonstrated knowledge of care management, utilization management and insurance industry.
Experience with financial reporting and analysis, preferably in a managed care setting.

Preferred Qualifications

Master's degree from an accredited university.
HMO and PPO care / utilization management experience.
Value Based Program expertise.

Time:  Full time
Salary:  Salary
Category:  Clinical/pharmacy/quality

Updated: 7/29/2024 10:08:00 AM