Sr. Director, Utilization Management - Behavioral Health

Job Summary:

The Senior Director, Utilization Management – Behavioral Health is responsible for leading and overseeing all aspects of behavioral health management within the utilization management organization. This role ensures the consistent and efficient delivery of services across the healthcare continuum, driving positive change for members.

Essential Functions:

• Collaborate with market and enterprise leaders to develop, implement and enhance effective behavioral health utilization management strategies and practices, ensuring knowledge transfer across the organization and compliance with regulatory standards.
• Proactively monitor and ensure compliance with regulatory requirements and state contract obligations for behavioral health services, adapting to new populations as needed
• Oversee the effective use of prior authorizations, policies, and benefits to guarantee a consistent, efficient delivery of services to members, while achieving internal financial objectives
• Facilitate the identification, analysis, and resolution of operational challenges within the behavioral health management framework
• Establish benchmarks, goals, and outcomes for all behavioral health programs, implementing an accountability system to monitor progress and performance
• Lead CQI initiatives in accordance with regulatory requirements and accreditation standards, ensuring high-quality service delivery
• In partnership with UM leadership, review and analyze reporting data to identify trends, uncover opportunities for improvement, and ensure alignment with policies and procedures
• Mentor and develop team members, fostering a culture of growth and professional development. Build a succession plan that includes managerial and team-level talent
• Cultivate and maintain strong relationships with hospitals, physicians, and community agencies to enhance member and provider satisfaction
• Identify and report risk management issues impacting the department and CareSource as a whole, ensuring proactive measures are taken to mitigate risks
• Monitor high-cost, high-volume, and high-risk conditions, ensuring effective management and resource allocation for all programs
• Perform any other job duties as requested

Education and Experience:

• Bachelor’s degree in nursing, behavioral health or related field required or equivalent years of relevant experience required
• Master’s degree preferred
• Minimum of seven (7) years of experience in behavioral health utilization management, quality improvement or service delivery required; experience in behavioral health, quality improvement or a related field preferred
• A minimum of five (5) years of experience in managed care required
• Minimum of five (5) years leadership experience required

Competencies, Knowledge and Skills:

• Proficiency in Microsoft Office products including Word, Excel and PowerPoint
• Internet research skills preferred
• Leadership experience and skills
• Strong understanding of regulatory and accreditation standards (e.g. NCQA)
• Change agent
• Decision making/problem solving skills
• Clinical data analysis and trending skills
• Critical and systems thinker
• Knowledge of trends in healthcare, managed care, Medicaid, behavioral health, and quality improvement
• Excellent communication skills, both verbal and written
• Management skills including human capital and project management
• Ability to work independently and within a team environment
• Attention to detail
• Understanding of predictive modeling process/tools
• Training/teaching skills
• Strategic management skills
• Negotiation skills/experience
• Politically astute
• Program grammar usage, phone etiquette and technical writing skills
• Time management skills
• Customer service oriented

Licensure and Certification:

• Current, unrestricted license as a Registered Nurse (RN), Licensed Social Worker (LSW), Psychologist, or Professional Clinical Counselor (PCC) is required
• Managed Care, Utilization management Case Management and/or Quality Improvement certification preferred

Working Conditions:

• General office environment; may be required to sit or stand for long periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.