Utilization Management Director

Chinese Hospital, a community-owned, not-for-profit organization, exists primarily to deliver quality health care in a cost-effective way, responsive to the community’s ethnic and cultural uniqueness, providing access to health care and acceptability to all socioeconomic levels, partnering with CCHP.

CCHP’s mission is to improve the health of our community by delivering high-quality, affordable healthcare through culturally competent and linguistically appropriate services. We welcome all cultures and in any language.

CCHP is looking for a Utilization Management Director.

The Utilization Management Director position is a vital leadership role that provides oversight of all aspects of the Utilization Management Program, day-to-day operations and staff to ensure service levels, business functions and all regulatory requirement goals are met. Working closely with CCHP leaders, the UM Director plans, executes and reports on administrative, operational and strategic objectives. Together with the UM Medical Director and UM Behavioral Health practitioner, collaborates in setting annual department goals and interventions and provides routine progress reports to stakeholders. The UM Director is involved in reviewing and making determinations on authorization requests and providing training and subject matter expertise to other departments as needed to ensure efficient utilization management.

The UM Director represents CCHP in the healthcare community both in the Bay Area and with out-of-area hospitals. In this role the UM Director actively and consistently fosters a positive and collaborative working relationship with CCHP’s community partners, contracted hospital transfer centers, nursing supervisors, and medical group Utilization Management (UM) nurses.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Provides clinical leadership and management to the UM department by managing the day-to-day operational functions.
• Routinely analyzes and reports UM metrics to identify trends and recommend interventions to the Medical Director and the UM QI Committee.
• At least annually, reviews all desktop procedures, and operational policies and procedures annually; revises and implements under the direction of the UM Medical Director.
• Conducts an annual assessment of operational processes to enhance departmental and interdepartmental accuracy and efficiency.
• Provides clinical review including high risk member reporting for the finance and claims department.
• Routinely monitors turnaround times for authorizations, denial letters and member notification of services, and productivity.
• Is a subject matter expert who can develop resource tools and education for the clinical and administrative staff.
• As a business leader supports the compliance department in maintaining compliance with state and federal requirements for the UM department and implements corrective action plans that address findings to maintain compliance.
• Serves as primary liaison with all delegated medical group UM departments, Chinese Hospital nurse leaders, community hospitals and transfer centers.
• Provides leadership in the design and implementation of UM policies, processes, and procedures needed to meet National Commission on Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC) accreditation requirements for all lines of business.
• Maintains knowledge of the UM software program functionality and collaborating with the IT team responsible for advising on replacement, upgrades, and user testing
• Conducts annual employee evaluations for licensed and non-licensed UM staff.
• Performs other duties as assigned by the Medical Director.

CORE COMPETENCIES

Must possess and consistently demonstrate the following competencies:

Decision Making and Judgment

• Coordinates cross-functional resources and ideas to align with organizational goals.
• Conducts root-cause analysis to uncover underlying issues and recommend effective solutions.
• Develops and evaluates a range of solutions, assessing benefits, costs, and risks associated with each.
• Interprets data to identify trends, draw conclusions, and present findings.

Teamwork

• Promotes a culture of mutual respect, fairness, and open communication among clinical and administrative staff.
• Supports team members in adapting to new protocols, technologies, or care models with confidence and encouragement.
• Build strong working relationships across departments, including nursing, physicians, case management, and administration.
• Preserves the dignity and confidence of colleagues by valuing diverse perspectives and contributions.

Continuous Improvement

• Demonstrates openness to innovative technologies, procedures, and organizational changes that enhance patient care and operational efficiency.
• Adapts to a variety of situations, individuals, and teams with professionalism and flexibility.
• Develop and test innovative solutions to address clinical and administrative challenges.
• Ensures accuracy and quality in all tasks, with a strong focus on detail and compliance.
• Promotes a culture of continuous learning and improvement throughout the organization.

Communication

• Keeps managers and team members informed of progress, challenges, and changes in plans or procedures.
• Ensures timely and accurate communication among all individuals involved in patient care or operational projects.
• Practices active listening by giving speakers full attention, maintaining eye contact, and responding appropriately.
• Encourages open dialogue and allow others to express themselves without unnecessary interruption.
• Builds and maintains positive relationships with co-workers, patients, and external partners.
• Asks clarifying questions and provide thoughtful answers to enhance the quality and reliability of shared information.
• Supports a respectful and inclusive workplace culture through professional and empathetic interactions.

Work Product Quality

• Adheres to all workplace safety laws, healthcare regulations, and organizational policies.
• Demonstrates openness to new procedures, technologies, and perspectives to improve outcomes.
• Responds positively to change and support others in adapting to evolving practices and values.
• Maintains confidentiality and upholds the highest standards of honesty and integrity in all interactions.
• Encourages and supports colleagues, contributing to a positive and collaborative work environment.
• Continuously seek ways to improve processes and patient experiences through innovation and dedication.

Customer Service

• Builds and maintains strong relationships with patients and members by delivering timely, respectful, and culturally competent service.
• Actively seeks feedback to ensure patient needs understood and met.
• Engage patients in identifying concerns, exploring options, and defining desired outcomes.
• Follows up to ensure that solutions are effective and satisfying.
• Delivers services when and where patients need them, ensuring accessibility and responsiveness.
• Remains committed to supporting patients beyond the initial interaction, fostering long-term trust.
• Anticipates emerging trends and communicate them to patients and internal teams to help prepare for future needs.
• Collaborates with internal departments to develop new services and service models aligned with patient expectations.
• Recognizes and responds to unspoken concerns with empathy and discretion.
• Provide sexcellent service to both internal (staff, providers) and external (patients, families) customers.

QUALIFICATIONS

• Current unrestricted license as a Registered Nurse issued by the State of California
• Bachelor’s degree in Nursing and a minimum of six years of experience in a health plan or patient care setting, which included a minimum of three years of utilization management experience and one year of case management experience and a minimum of three years of experience supervising and training clinical staff
• A Master’s degree may substitute for two years of the required experience); or an equivalent combination of education and experience
• Strong knowledge of current NCQA, DMHC, DHS and CMS regulatory UM standards

(this is a teachable skill not a qualification)

• Ability to present strategic information, data and results in a clear and understandable manner utilizing methods appropriate to various forums.
• Flexibility, adaptability, problem solving capability, creativity, initiative, teamwork and the ability to work with a broad range of constituencies.
• Strong customer service skills
• Ability to establish and maintain productive business relationships, manage conflict and negotiate solutions.
• Excellent time management, organizing and coordinating skills.
• Ability to make management decisions and judgments on sensitive and confidential issues.
• Ability to work independently, set and change priorities quickly and as the situation warrants.
• Strong skills in Microsoft applications including MS Office and Excel.

Salary: $135,928 – $203,715