The Senior Director, Utilization Management and Operations will oversee the direction and provide leadership to clinical and clinical support staff to support positive health and financial outcomes of Medi-Share membership in accordance with the member-voted Guidelines. This role will design and develop clinical strategies to achieve and maintain optimal wellness outcomes and make decisions related to identifying and resolving complex technical and operational problems within the healthcare experience. The Director, Utilization Management and Operations ensures the delivery of high-quality, cost-effective care to members through effective care coordination and case management.

• Oversee the Care Management function that assists Medi-Share members in achieving an optimal level of wellness and coordination of their care; helping them identify cost-effective and non-duplicative services while they are in a time of great need and potential crisis
• Develop and ensure the effective delivery of education to members regarding the provisions of their Program Guidelines relative to healthcare, nursing, rehabilitative, and spiritual services
• Provide direction to Care Management staff including, but not limited to hiring, training, and communication regarding policy and procedural changes and monitoring and evaluating the quality of all processes
• Perform and/or administer research in ensuring effective, timely responsiveness to Care and Case Management issues; if required, handoff to Chief Medical Officer, providing required research and recommendation summary
• Act as liaison between member and/or provider to bring about resolution when conflicts arise
• Maintain awareness and be alert to member and provider issue trends and escalating concerns, and recommend resolutions
• Collaborate with other internal teams and stakeholders to ensure timely and accurate determination of sharable services
• Define and manage pre-service eligibility determinations (EDI 278) and associated standard operating procedures
• Define and manage concurrent review processes to effectively manage length of stay and facilitate discharge planning
• Oversee the preparation of various telephone scripts
• Update and maintain the policy and procedure manual
• Maintain the High Priority queue in conjunction with fellow Directors and Chief Medical Officer
• Assist in developing projects, policies, procedures, and other related issues as required
• Support the strategic vision delineated by the Chief Medical Officer and the Ministry
• In coordination with the Chief Medical Officer, organize and staff the Department in a manner that provides optimal service to the members and membership
• Ensure department Managers are successful in workforce, quality, and performance management (as elsewhere delineated)
• Define performance and attendance expectations of department Managers
• Review weekly performance reports submitted by department Managers
• Submit monthly performance reports to the Chief Medical Officer of all staff under Director
• Contribute to the exercise and expression of Christian Care Ministry’s Christian beliefs
• All other duties as assigned

• Bachelor’s degree in Nursing, Social Work, Healthcare Management or closely related field with 8+ years’ experience in a healthcare payer organization, or equivalent experience required
• Master’s or Doctorate degree in Healthcare Administration (MHA), Healthcare Clinical or Operations Management or similar accredited program preferred
• 5+ years’ previous utilization review and clinical people leadership experience in a healthcare payer organization required
• Experience in a value-based care organization preferred
• Experience in Care Management with understanding of population health and risk stratification principles preferred