Director of Utilization Management and Complex Care Management

Job Summary

The Director of Utilization Management and Complex Care Management provides leadership to and is responsible for the transitional care management and complex care management teams. These teams leverage utilization management clinical criteria (MCG), best in class transitional care management, and proven whole-person complex care management pathways to:

1. Engage and build trust with our members
2. Deploy member-centric interventions to provide best in class clinical outcomes
3. Ensure appropriate facility/hospital length of stay
4. Reduce readmissions and overall bed days

This integral role combines strategic planning with hands-on operational oversight to meet clinical, financial, quality, and contractual success. Success in this role is measured by meeting and/or exceeding KPI targets around member engagement, Admissions, Readmissions, ED visits/1000, SNF days/1000, and length of stay.

The role will need to work well within a matrixed integrated management structure including National Shared Services leaders and Market Leadership.

Duties and Responsibilities

• Manage and lead an integrated care team directly or with supervisory leaders to reduce total cost of care and appropriately reduce admissions/1000, readmissions/1000, ED visits/1000, SNF days/1000, and length of stay. For markets with MCG ensure staff execute MCG effectively and consistently.
• Use data analytics to monitor team/contractual performance and create action to improve utilization, clinical outcomes, quality metrics, and member satisfaction. Ability to leverage reporting to create action and drive key value outcomes.
• Establish and maintain strong collaborative external relationships and partnerships: hospitals, skilled nursing facilities, home health agencies, and community-based organizations (housing food), community providers, and specialists.
  • Hospital care management, discharge planning teams and facility leadership highlighted as critically important.
  • Leverage SDoH interventions
  • Lead collaborative rounds with health plan partners
• Maintain strong relationships with our health plan partners and ability to lead utilization management rounds with plan partners.
• Establish department goals, manage clinical financial risk, and address operational issues to ensure performance meets or exceeds contractual objectives.
• Serve as an SME in complex care management, Transitional Care Management and therapeutic approaches, enabling evidenced based best practices in member care through training and evidence-based guidance.
• Address complex needs of populations facing medical, behavioral, and socioeconomic barriers using data-driven, empathetic interventions, such as motivational interviewing and trauma-informed care.
• Partner with HR partners to ensure effective clinical recruitment and with shared services partner for effective and efficient new team member onboarding.
• Ensure team compliance with Program policies and procedures and attends required training
• Manage caseloads to ensure follow-up, timely documentation, and regulatory compliance.
• Lead and manage a diverse care management team, including registered nurses, social workers, and other support roles
• Oversee staff development and adherence to best in class care standards, including person-centered integrated care planning, SMART goals, and NCQA/regulatory documentation protocols.
• Conduct performance activities such as case audits, coaching, and training to maintain compliance with quality and accreditation standards.
• Oversee hiring, onboarding, and training processes for new team members, aligning team growth with organizational objectives.
• Engage team members through regular meetings, team-building activities, and virtual or in-person morale-building efforts. Includes have routine 1:1 meeting with the team.
• Responsible for employee engagement and staff turnover rates of their areas of responsibility.
• Host interdisciplinary care team (ICT) meetings, ensuring follow-up on action items to enhance member outcomes.
• If warranted, will direct a lead role who will be a subject matter expert with departments workflows, tools, and processes.
• Identify low-performing staff or processes, implementing performance improvement plans as needed.
• Fosters an environment of accountability, teamwork and collaboration within and among care and support teams
• Ensures leaders are prepared and able to effectively handle huddles and meetings effectively and efficiently
• Addresses low performance swiftly, fairly and timely
• Works in partnership with medical directors to continuously develop clinical and support team members skills and knowledge to optimize impact to member outcomes and experience
• Ensures quality review and oversight of individual and team performance on a regular basis
• For sites with NCQA Accreditation- ensure continuous compliance with NCQA CM standards
• Actively participates in Clinical Program enhancements and ensures effective execution

Stakeholder Engagement and Representation

• Represent the department in senior management and external partner meetings, aligning operations with organizational strategy and fostering stakeholder relationships.
• Support customer resolution efforts, coaching team leaders on best practices and managing escalated cases as necessary.

Compliance and Additional Responsibilities

• Ensure adherence to privacy, HIPPA, and security standards for member information, meeting all organizational and legal requirements.
• Adapt to dynamic work environments and manage competing priorities through flexible, innovative solutions.

• Oversee recruitment activities, determine staffing needs, and retain qualified personnel to meet operational objectives.
• Ensure best-in-class bed day management, transitional care, and complex case management
• Achieve market KPI goals -engagement, clinical, and financial

Minimum Qualifications

• Licensure and Education
• Minimum License: Current, active, and unrestricted license RN highly desired (and required if directly supervising non-RNs, licensed professionals doing complex care management or transitional care management, if not, may have an LCSW, LMSW OR in a health or human services discipline that, within its scope of practice, allows you to conduct an assessment independently.
• Certifications Highly Desired in this Role: Qualified with CCM Credentials- CMGT-BC, CCTM, C-SWCM, C-ASWCM, ACM or FAACM will be considered. BLS/CPR required.
• Education: Minimum degree required for license per state of practice.
• Master’s degree in business, Healthcare Administration/Public Health, Finance, or a related field a plus.
• Advanced clinical practice (e.g. APN/DNP, LCSW/LISW, PsyD/PhD) a plus
• Other Certifications Considered: CMAC, CHE, CPHQ or similar certifications a plus.
• Experience
• 10+ years’ experience, with 5-7 years in leadership,
• A leadership position with a proven successful track record helping manage an At Risk Value-Based Care Model, Utilization Management, Transitional Care Management, and Complex Care Management
• A track record of success managing transitional care management/evidence-based care transition strategies, including discharge planning, post-acute skilled nursing facilities, and community-based care coordination.
• Inpatient and/or ED hospital care management/discharge planning leadership experience
• Health plan experience a plus.
• Experience with complex, vulnerable populations (e.g., Medicaid, Medicare, dual-eligibles), including medically complex, trauma-experienced, and socially vulnerable individuals.
• Including experience with Severe Mental Illness (SMI) and Substance Use Disorders (SUD)
• Technical and Analytical Skills
• Advanced computer skills in Microsoft Office Suite, electronic health record (EHR) systems and Case management systems.
• Familiar with AI tools and has some experience using in workplace
• Strong data analysis and reporting abilities to drive performance improvements and process optimization.
• Interpersonal and Communication Skills
• Excellent verbal and written communication skills for interactions with members, families, stakeholders, and interdisciplinary teams.
• Proven ability to foster team morale, handle change, and work independently while making sound clinical judgments.

Working conditions

• Ability to work both in community settings and in a professional office environment.
• Ability to operate electronic portable devices and complete documentation and other tasks in a mobile work environment.
• Ability to travel regionally and nationally up to 80%
• Expected to spend time in local facilities (ie – hospitals) as well as our centers.

Physical requirements

• Ability to operate computer, keyboard, copy and fax machine, phone, and other general office equipment.

• Ability to occasionally move objects up to 20 lbs.

• Valid driver’s license with automobile insurance.
• Reliable transportation.

Direct reports

Transitional Care Team, Center, Complex Care Management Team, Community Complex Care Management team. May include any combination of:

• Managers
• Supervisors
• Leads
• Direct CTCM/CCM staff