Nursing Director - Utilization Management

Nursing Director - Utilization Management

Who We Are:

TurningPoint Healthcare Solutions is a leader in advanced clinical and technology-enabled complex condition management. TurningPoint provides an innovative suite of specialty care management services and technologies that enable health plans and employers to improve the safety, quality, and affordability of healthcare. Through its platform and specialized team of clinical experts, TurningPoint works collaboratively with providers to deliver optimal care. TurningPoint offers condition-specific, quality-driven, value-based care management services that optimize care from diagnosis and discovery through recovery. TurningPoint's comprehensive and integrated suite of services enhances the support individuals need, at the time they need it most. Since launching in 2015, TurningPoint has provided support to more than 50 million people nationwide across numerous clinical specialties including musculoskeletal, pain management, cardiology, wound care, ear/nose/throat, and sleep. TurningPoint's model moves beyond denial-based care to holistic condition management that improves outcomes and reduces cost. TurningPoint is an independent organization, not owned or affiliated with a health plan or provider system.

Position Summary:

Determines the Utilization Management Departments operational strategies by conducting needs assessments, performance reviews, capacity planning, and cost/benefit analyses; identifying and evaluating state-of-the-art technologies; defining user requirements; establishing specifications for productivity, quality, and customer-service standards; contributing information and analysis to organizational strategic plans and reviews.

Roles and Responsibilities:

• Maintains and improves productivity and operations by monitoring system performance; identifying and resolving problems; preparing and completing action plans; completing system audits and analyses; managing system and process improvement and quality assurance programs; installing upgrades.
• Accomplishes human resource objectives by recruiting, selecting, orienting, training, assigning, coaching, counseling, and disciplining employees; administering scheduling systems; communicating job expectations; planning, monitoring, appraising, and reviewing job contributions; planning and reviewing compensation actions; enforcing policies and procedures.
• Meets financial objectives by estimating requirements; preparing an annual budget; scheduling expenditures; analyzing variances; initiating corrective actions.
• Prepares performance reports by collecting, analyzing, and summarizing data and trends.
• Develops and administers policies and procedures for utilization control of inpatient and outpatient services.
• Responsible for the maintenance of good community relationships with providers and clients to ensure a responsive system for authorization of services and payment of claims.
• Prepares statistical and narrative reports as requested by administrative staff on utilization patterns, expenditures by area and revenue stream, demographics of service delivery and trending of expenditures by program.
• Trains professional clinic and program staff on current principals and standards of practice of Utilization Management, medical/surgical diagnosis and treatment coding and reimbursement methodologies.
• Maintains professional and technical knowledge by tracking emerging trends in call center operations management; attending educational workshops; reviewing professional publications; establishing personal networks; benchmarking state-of-the-art practices; participating in professional societies.
• Accomplishes organization goals by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.
• Follows company policies and procedures and conducts annual performance reviews in a timely manner.
• Respects and maintains HIPAA confidentiality guidelines.
• Other duties as directed.

Education, Experience and Licensure:

• Bachelor/Master/Doctorate Degree in Nursing or Pharmacy. Minimum of 5 years' experience in Utilization Management/Managed Care environments required.
• Excellent verbal and written communication skills.
• Strong leadership skills in the areas of staff development, performance improvement with demonstrated results.
• Ability to foster a cohesive working environment.

Preferred Skills:

Customer Focus, Customer Service, Verbal Communication, Informing Others, Process Improvement, Problem Solving, People Skills, Teamwork, People Management, Managing Processes, Emphasizing Excellence.

TurningPoint Healthcare Solutions is an Equal Opportunity Employer.