Managed Care Utilization Review Director

Managed Care Utilization Review Director III Job Description:
The Texas Health and Human Services Commission (HHSC) Medicaid CHIP Services (MCS) department seeks a highly qualified candidate to fill the position of Managed Care Utilization Review (UR) Director. MCS is driven by its mission to deliver quality, cost-effective services to Texans. This position makes a significant contribution to MCS’s mission by providing oversight of Medicaid Managed Care Organizations’ delivery of high quality, cost effective, and timely services.

The Managed Care UR Director reports to the Deputy Associate Commissioner of UR and is responsible for providing clinical and contract oversight of Medicaid managed care programs. This position is directly responsible for strategic direction and day-to-day management of three highly specialized teams that have a wide array of management level positions, licensed or certified clinical and professional staff: Acute Care UR, UR Operations, and Long Term Services and Supports UR.  The Managed Care UR Director directly supervises the managers of these teams and indirectly supervises approximately 100 staff including those located in regional offices statewide, who perform complex and highly technical functions. 

The Managed Care UR Director functions as part of the Office of Medical Director (OMD) leadership team and will help drive the expanded scope of the UR team to provide increased scrutiny of service delivery, care coordination, coordination of benefits, and clinical appropriateness in all Medicaid managed care programs. This position provides direction and guidance in strategic operations and planning to achieve the goals and objectives for UR with a priority focus on cases with the highest health and fiscal risk. The Managed Care UR Director will work under minimal supervision, with extensive latitude for the use of initiative and independent judgment.

The ideal candidate thrives in an environment that emphasizes: teamwork to achieve goals, excellence through high professional standards and personal accountability, curiosity to continuously grow and learn, critical thinking for effective execution, and integrity to do things right even when what is right is not easy.

Essential Job Functions:

Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.

20% Directs and organizes UR activities to ensure Medicaid managed care programs are delivered efficiently and effectively and are in compliance with federal and state laws, regulations, policies, and HHSC contracts and guidance. Direct teams and provide guidance to identify problems, evaluate alternatives and implement effective solutions for continuous improvement in the utilization review process. Directs and works with teams to develop internal standard operating procedures to standardize processes between teams and identify the need to revise them in order to evaluate and update program activities. Prioritizes activities that have the highest impact on health outcomes and cost savings.

20% Directs, manages, supervises, hires and develops professional and management staff for designated Managed Care UR units. Provides effective direction and leadership to staff within the managed care UR team and holds them accountable for achieving performance expectations, stated program goals and legislative mandates.  Utilizes knowledge of human resource management including budgeting, compensation, classification, performance management and selection procedures.

15% Represents the agency at business meetings, hearings, trials, legislative sessions, conferences, and seminars or on boards, panels, and committees. Responds to external stakeholder inquiries on behalf of the agency. Exhibits skill in communicating orally and in writing, through technical report writing, creation of presentations to agency leadership, across agencies, and to external stakeholders such as advisory and advocacy groups.

15% Develops Managed Care UR strategic plan, program goals, strategies and initiatives to align with the Medicaid and HHSC strategic plans.  Provides oversight of associated workplans.  Analyzes and evaluates highly complex program and policy issues affecting utilization review processes.

15% Develops and implements techniques for evaluating program activities, and reports findings and recommendations for improvements to executive staff. Oversees the collection and analysis of complex data sets along with resulting reports. Evaluates complex legislative directives, policies and procedures and direct their effective implementation.

10% Provides effective communication to include: keeping the UR Deputy Associate Commissioner, Medicaid and CHIP Chief Medical Director, MCS leadership, and other OMD/UR staff informed of program issues; communicating program goals, objectives and changes to program staff; establishing and maintaining effective working relationships; and responding to requests for information in a timely manner.

5% Develops and manages departmental budget and HHSC resources efficiently and effectively.  Assist in the development of HHSC legislative appropriations requests, federal funding requests and grant requests to ensure adequate support and funding for UR functions.  

Knowledge Skills Abilities:
Experience in managing and directing complex programs, including experience in an executive or senior management capacity.

Experience with Texas Medicaid managed care program.

Knowledge of governmental or non-governmental public health programs.

Knowledge of the role of federal and state laws, regulations, policies, and procedures in management of publicly funded health care services.  

Knowledge of UR and management federal and state laws, regulations, policies, and HHSC contracts and guidance.

Knowledge of human resource management including budgeting, compensation, classification, performance management and selection procedures.

Knowledge of the State of Texas legislative process.

Ability to develop and implement strategic plans, goals, objectives, and evaluation tools and reports to monitor progress and ensure accountability.

Ability to monitor and direct multiple interrelated projects and initiatives through appropriate project/program management techniques.

Ability to effectively manage employees; i.e. recruit, hire, develop, performance management, ensure accountability, and motivate to build morale.

Skill in the application of risk management strategies including the ability to routinely identify, manage and effectively mitigate risks.

Skill in communicating orally and in writing, through technical report writing, creation of presentations to agency leadership, across agencies, and to external stakeholders such as advisory and advocacy groups.

Skill in analyzing and evaluating highly complex program and policy issues affecting utilization review processes. Ability to evaluate complex legislative directives, policies and procedures and direct their effective implementation.

Knowledge of quality assurance oversight functions in a business environment.

Ability to facilitate effective issue resolution through dialogue, alternative analysis and consensus building techniques.

Ability to communicate effectively, verbally in formal and informal settings and in writing to include emails and complex reports.

Ability to build and maintain effective working relationships, negotiate with individuals and groups internally and externally, develop professional networks with other organizations, and to identify the internal and external dynamics that impact the work of the organization.

Ability to develop and manage department budgets and resources. 

Ability to work collaboratively with other divisions of the enterprise on procurements and contracts.

Ability to effectively oversee outsourced projects including approval of project timelines, deliverables, implementation and operations as well as the vendor performance required under the contract.

Initial Selection Criteria:
8 + years of experience in managing and directing complex programs of which three years should be in an executive or senior management capacity.

Experience with Texas Medicaid managed care program.

3+ YEARS leading or performing UR/utilization management.

Experience in a leadership role in a clinical setting or related experience.

Bachelor’s or Master’s degree in relevant field,  such as health sciences, public health,  health care or equivalent experience

Registration or Licensure Requirements:
None.  Preference may be given to candidates with degrees in health sciences, health care, or public health. Preference may also be given to candidates with relevant master’s level degrees (e.g. in nursing, health care administration, or public health).