Director, Utilization Management

Director, Utilization Management

We are seeking a Director, Utilization Management to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations.

The Director of Utilization Management plays an essential role in ensuring that healthcare services are delivered efficiently and effectively while maintaining high standards of member care. The Director of Utilization Management is responsible for overseeing the utilization management department, developing policies and procedures that align with regulatory requirements, and implementing best practices to optimize resource use. The Director of Utilization Management will collaborate with clinical teams to assess the appropriateness of care and ensure that members receive the right services at the right time. Additionally, the Director of Utilization Management involves analyzing data to identify trends and areas for improvement, ultimately enhancing member outcomes and satisfaction. The Director of Utilization Management will lead initiatives that promote cost-effective care while ensuring compliance with healthcare regulations and standards.

Minimum Qualifications:

• Bachelor's degree in Nursing, Healthcare Administration, or a related field.
• 5 years of experience in utilization management or a related healthcare field.
• Strong knowledge of healthcare regulations, policies, and best practices.

Preferred Qualifications:

• Master's degree in Healthcare Administration, Public Health, or a related field.
• Certification in Utilization Management (e.g., ACM, CCM) is highly desirable.
• Experience in a leadership role within a healthcare organization.

Responsibilities:

• Demonstrate commitment to Our Mission and models ILS Experience Standards of Excellence.
• Lead and direct a team of utilization management professionals, fostering a culture of continuous improvement and excellence.
• Direct the daily operations of the utilization management department, ensuring compliance with all regulatory requirements.
• Develop and implement utilization management policies and procedures that align with organizational goals.
• Collaborate with clinical staff to review and assess the appropriateness of care provided to members.
• Analyze utilization data to identify trends, areas for improvement, and opportunities for cost savings.
• Ensure that assigned deliverables are completed on time, including development and coordination of required contractual and regulatory submissions.
• Develop and track key performance indicators (KPIs) to measure organizational performance, including accurate and timely reporting of required contractual regulatory reports.
• Develop, maintain and improve management processes, policies and procedures and/or conduct management projects including development of detailed plans to achieve project objectives.
• Perform other duties as assigned.