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Full-time
bachelor degree, postgraduate degree
Posted 18d ago
Apply by Nov 23
~40 hrs/week
Responsibilities
The Director of Utilization Management oversees the Referrals Department and RN Case Managers to ensure efficient healthcare resource utilization and high-quality care delivery. This role involves developing policies, analyzing clinical data, and collaborating with leadership to improve patient outcomes and organizational compliance.
Requirements
Candidates must hold a BSN with a valid multistate license and a Master's degree in nursing, Public Health, or a related field. A minimum of 10 years of progressive healthcare administration experience, including at least 5 years in a leadership role, is required.
Full job description
Position Summary:
The Director of Utilization Management at Palm will be responsible for overseeing the Referrals Department and RN Case Managers across our network of primary care clinics. This leadership role ensures that appropriate utilization of healthcare resources is aligned with company standards, regulatory requirements, and quality care practices. The Director of Utilization Management will work closely with healthcare providers, staff, and senior leadership to improve patient care, streamline referral processes, and manage care coordination across the organization.
Key Responsibilities:
Direct the day-to-day operations of the Referrals Department and RN Case Managers to ensure high-quality care and service delivery.
Provide strategic leadership in optimizing patient referrals, case management practices, and healthcare resource utilization.
Manage and mentor a team of clinical and administrative staff, fostering a collaborative and patient-centered work environment.
Develop and implement policies and procedures for effective referral management and case coordination.
Oversee the utilization review process, ensuring appropriate utilization of services and adherence to best practices and guidelines.
Monitor referral patterns and case management outcomes, analyzing trends and making recommendations for process improvements.
Ensure that the organization meets all regulatory and accreditation standards in relation to utilization management.
Work closely with clinical teams, including providers and any other medical professionals, to promote efficient care coordination and utilization management.
Serve as a key liaison between the Utilization Management team, senior leadership, and other departments within Palm.
Collaborate with external partners, such as insurance companies and healthcare networks, to facilitate care transitions and referrals.
Analyze clinical and financial data to track utilization patterns, ensuring resources are used efficiently and effectively, including cost reallocation process.
Report regularly to senior leadership on utilization trends, case management outcomes, and potential areas of improvement.
Identify opportunities to reduce unnecessary utilization, improve cost-effectiveness, and enhance patient care outcomes.
Ensure compliance with all relevant healthcare regulations, standards, and internal policies.
Develop and implement quality improvement initiatives related to case management, referral
processes, and overall care coordination.
Lead and participate in audits, assessments, and reviews related to utilization management and patient care quality.
Qualifications:
Education:
RN BSN, with a valid multistate license. Master's degree in nursing, Public Health of a related field.
Experience:
Minimum of 10 years of progressive experience in healthcare administration, with at least 5 years in a leadership role in utilization management, case management, or a related field.
Experience working in a primary care setting or with a network of primary care clinics is highly preferred.
Proven track record of managing referral processes, case management teams, and optimizing resource utilization.
Skills & Competencies:
Strong knowledge of utilization management processes, clinical guidelines, and healthcare regulations.
Excellent leadership, team building, and communication skills.
Ability to analyze complex data, identify trends, and develop actionable strategies for improvement.
Strong problem-solving and decision-making abilities.
Proficient in electronic health records (EHR) systems and other healthcare management software.
Work Environment:
This position will be based in the corporate office with travel required to various center locations.
Palm Medical Centers is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Palm Medical Centers makes hiring decisions based solely on qualifications, merit, and business needs at the time.
At Palm Medical Centers, we offer premier primary care for seniors 65+ with Medicare Advantage plans at numerous locations throughout Central Florida and South Florida.
We are committed to providing our patient members with the Palm Medical Experience. At each of our multiple locations, patients will find attentive doctors, knowledgeable and compassionate care coaches, and professional staff who focus on the needs of patients from the diverse communities we serve. By taking the time to build relationships with every patient who walks through our doors, we are better able to offer customized solutions designed to optimize each patient’s health and well-being. Everything we do is rooted in the belief that everyone we treat deserves to enjoy the Palm Medical Experience – which contributes to our patients becoming happier, healthier versions of themselves.
Senior Primary Care with Genuine Kindness!
Offices: 2600 South Douglas Road, Suite 308, Coral Gables, FL, 33134 305-913-9441, US · 1251 NW 36th Street, Miami, FL, 33142 786-693-1206, US · 16795 NW 67th Avenue, Miami Lakes, FL, 33015 786-693-1236, US · 6849 Taft Street, Hollywood, FL, 33024 954-639-4578, US · 16241 Biscayne Boulevard, Aventura, FL, 33160 786-629-7558, US