About the Position:
The Director, Utilization Management position supports our global growth by helping U.S. health insurers overcome the challenges of the nursing shortage and workflow efficiency. It focuses on serving existing client success in coordination with our U.S. based Account Managers and the ability to grow our presence with the client. It will also have a strong emphasis on contributing to a diligent discovery process with new clients, clinical input for implementation plans, and coordination with our Philippines operations team to ensure efficient high-quality work. Because we are a versatile, fast-growing company, the position will also support new product development and the development of new international relationships.
The position is based in Nashville, TN.
As the Director, Utilization Management you will:
- Act as the utilization management subject matter expert.
- Be an active participant and support for the utilization management leadership and production staff.
- Support and assist in implementation of new utilization management programs.
- Oversee UM nurse and peer review nurse qualification standards and staff selection.
- Align business and clinical objectives related to UM workflows.
- Provide education and training based on gaps identified in clinical knowledge and medical necessity in compliance with industry accepted best practices.
- Lead role in monitoring performance improvement.
- Acts as Chair of Utilization Management Committee.
- Champion nursing and physician partnership in utilization management review cycle.
- Provide guidance for programs involving care coordination and case management programs.
- Provide clinical and industry thought leadership for marketing new opportunities.
- Participate in the discovery, evaluation, and solutioning of new clinical services.
- Address client escalations regarding relevant workflows.
- Participate in key client quarterly business reviews as clinical leadership representative.
- Travel approximately 33% to domestic and/or international locations.
- Report directly to the SVP, Clinical Operations.
- A BSN or MSN
- Active and unencumbered nurse license
- 3-5 years of in-patient or emergency hospital-based nursing experience
- 3-5 years of leadership experience
- 3-5 years of experience working in areas focused on utilization management, UM quality analysis, and performance improvement
- Knowledgeable in various guidelines including: NCQA, CMS, Medicare/Medicaid, evidence-based guidelines including but not limited to MCG and Interqual
- Experience in designing effective value-based care models, protocols, and clinical training to decrease inappropriate utilization and/or enhance quality of outcomes
- Demonstrated commitment to patient-centered model of care delivery with proven quality management/improvement record
- Ability to travel domestically and/or internationally at least 33% of expected work hours
It would be a bonus if you….
- Have a master’s degree in business administration, healthcare, and/or nursing
- Have ever worked in a position as a liaison between healthcare entities or teams
- Have worked with remote teams
- Have experience working with team members from diverse cultural backgrounds
About Our Culture:
We get to create a win-win-win scenario in the marketplace:
- We help hospitals achieve improved nurse staffing levels through the placement of caring, international nurses; a win for the patient.
- Our clinicians overseas work 24/7 to ensure our patient needs in the U.S. are met through diligent Utilization Management, Health Coaching, HEDIS Gap Closure, Coding, Clinical Documentation Improvement, etc.
We are a nimble team, with virtually no red tape and a keen interest in what is possible.
Our people have the opportunity to take on new challenges in a way that is not available in most other companies. We value career development and achieve this not through emphasizing courses, certifications, and personality tests, but by giving our people an opportunity to lead, manage new projects, and get results.
Check us out on YouTube – we dare you!
We are building an amazing team, and when you join this resourceful, enthusiastic, hard-working group, you will have:
- A competitive salary
- Health insurance
- 401(k) with match
- Paid holidays
- Paid vacation and sick time
- The opportunity to stretch your wings and build your career in a rewarding, life changing, unforgettable way.
Because of a shortage of clinicians, it’s difficult to scale healthcare organizations. Shearwater Health provides teams of remote and onsite clinicians that expand the size and impact of clinical teams, so that clients can focus on internal teams practicing at the peak of their license.
From bedside to back-office, there are over 3,000 Shearwater clinicians solving medical and administrative problems every hour of every day all over the world. We couple our clinical expertise with Six Sigma business experts and Robotic Process Automation to improve outcomes and lower costs.
To be successful in our overarching solution to expand the size and impact of U.S. clinical teams both on-site in hospitals and off-shore in the Philippines, we cultivate a dedicated team passionate about finding the right talent and providing that talent with the right tools and training to provide quality work and care.