Director of Utilization Management

Position Summary:

The Director of Utilization Management at Palm will be responsible for overseeing the Referrals Department and RN Case Managers across our network of primary care clinics. This leadership role ensures that appropriate utilization of healthcare resources is aligned with company standards, regulatory requirements, and quality care practices. The Director of Utilization Management will work closely with healthcare providers, staff, and senior leadership to improve patient care, streamline referral processes, and manage care coordination across the organization.

Key Responsibilities:

• Direct the day-to-day operations of the Referrals Department and RN Case Managers to ensure high-quality care and service delivery.
• Provide strategic leadership in optimizing patient referrals, case management practices, and healthcare resource utilization.
• Manage and mentor a team of clinical and administrative staff, fostering a collaborative and patient-centered work environment.
• Develop and implement policies and procedures for effective referral management and case coordination.
• Oversee the utilization review process, ensuring appropriate utilization of services and adherence to best practices and guidelines.
• Monitor referral patterns and case management outcomes, analyzing trends and making recommendations for process improvements.
• Ensure that the organization meets all regulatory and accreditation standards in relation to utilization management.
• Work closely with clinical teams, including providers and any other medical professionals, to promote efficient care coordination and utilization management.
• Serve as a key liaison between the Utilization Management team, senior leadership, and other departments within Palm.
• Collaborate with external partners, such as insurance companies and healthcare networks, to facilitate care transitions and referrals.
• Analyze clinical and financial data to track utilization patterns, ensuring resources are used efficiently and effectively, including cost reallocation process.
• Report regularly to senior leadership on utilization trends, case management outcomes, and potential areas of improvement.
• Identify opportunities to reduce unnecessary utilization, improve cost-effectiveness, and enhance patient care outcomes.
• Ensure compliance with all relevant healthcare regulations, standards, and internal policies.
• Develop and implement quality improvement initiatives related to case management, referral
• processes, and overall care coordination.
• Lead and participate in audits, assessments, and reviews related to utilization management and patient care quality.

Qualifications:

Education:

• RN BSN, with a valid multistate license. Master's degree in nursing, Public Health of a related field.

Experience:

• Minimum of 10 years of progressive experience in healthcare administration, with at least 5 years in a leadership role in utilization management, case management, or a related field.
• Experience working in a primary care setting or with a network of primary care clinics is highly preferred.
• Proven track record of managing referral processes, case management teams, and optimizing resource utilization.

Skills & Competencies:

• Strong knowledge of utilization management processes, clinical guidelines, and healthcare regulations.
• Excellent leadership, team building, and communication skills.
• Ability to analyze complex data, identify trends, and develop actionable strategies for improvement.
• Strong problem-solving and decision-making abilities.
• Proficient in electronic health records (EHR) systems and other healthcare management software.

Work Environment:

• This position will be based in the corporate office with travel required to various center locations.

Palm Medical Centers is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Palm Medical Centers makes hiring decisions based solely on qualifications, merit, and business needs at the time.