Director of Utilization Management

Employment Type: Full timeShift: Day Shift Description: Why MediGold?

MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.

Position Purpose: Director Utilization Review directs the department's activities and resources to ensure alignment with the mission, values, and objectives of the department and organization

What you will do:

• Develops and implements departmental strategic goals, plans, and standards consistent with the clinical, administrative, legal, and ethical requirements/objectives of the organization. Oversees compliance with regulations, laws and ethics via audits and direct observation. Provides leadership in developing and implementing standardized tools, roles and systems to support Utilization Review
• Directs and evaluates departmental operations. Leads operational improvements to facilitate standardization of utilization review practices. Establishes metrics to achieve service targets. Oversees and evaluates programs and services focused on continuous quality improvement. Participates in review of contracts and agreement of services
• Plans and monitors staffing activities, including hiring, orienting, evaluating, disciplinary and continuing education initiatives. Develops network of high performing teams
• Prepares, monitors, and evaluates departmental budgets, and ensures that the department operates within the allocated funding
• Participates as an active management member of the Mount Carmel Health Plan representing the Utilization Review Department in collaboratively meeting operational, budget, and strategic planning goals

Minimum Qualifications:

• Education: Bachelor of Science Degree in Nursing, Business or other Healthcare related field. Master's Degree preferred
• Licensure/ Certification: RN License through the State of Ohio
• Experience: 10+ years experience in clinical nursing and utilization management with at least 3+ years of utilization management experience at a Managed Care organization.
• Working knowledge of utilization review practices related to regulatory and accreditation requirements.
• Proven team leader with the ability to interact with all levels of staff members and physicians and other healthcare providers.
• Ability to prioritize issues and solve complex problems.
• Proficient computer, written and verbal communication skills including presentation skills.
• Innovative and self-directed.
• Demonstrates a high tolerance for ambiguity and change and provides leadership to department colleagues and others to adapt effectively to meet changing environment.

Position Highlights and Benefits:

• Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.
• Retirement savings account with employer match starting on day one.
• Generous paid time off programs.
• Employee recognition programs.
• Tuition/professional development reimbursement starting on day one.
• RN to BSN tuition 100% paid at Mount Carmel’s College of Nursing.
• Relocation assistance (geographic and position restrictions apply).
• Employee Referral Rewards program.
• Mount Carmel offers DailyPay - if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday. You deserve to get paid every day!
• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.

Ministry/Facility Information: Mount Carmel, a member of Trinity Health, has been a transforming healing presence in Central Ohio for over 135 years. Mount Carmel serves over 1.3 million patients each year at our five hospitals, free-standing emergency centers, outpatient facilities, surgery centers, urgent care centers, primary care and specialty care physician offices, community outreach sites and homes across the region. Mount Carmel College of Nursing offers one of Ohio's largest undergraduate, graduate, and doctor of nursing programs. If you’re seeking a rewarding career where your purpose, passion, and desire to make a difference come alive, we invite you to consider joining our team. Here, care is provided by all of us For All of You!

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.