Senior Director, Complex Care Management and Utilization Management

2756

Remote?: 1

Highlights (Bonus, shift, relocation, info for job):

• This role will involve up to 40% Travel across AbsoluteCare locations 
• RN license preferred.
• Certification in Case Management (CCM), Utilization Review Accreditation Commission (URAC), or related credentials is a plus. 

Position Summary 

The Senior Director, Complex Care Management (CCM) and Utilization Management (UM) is a strategic senior leader position that is responsible for designing, implementing, and optimizing integrated care delivery models that improve health outcomes for medically and socially complex populations. This role oversees the national CCM and UM programs, ensuring alignment with at-risk value-based care principles, transitional care management, regulatory compliance, and operational excellence across all markets. Experience with delegated care management and/or utilization management from a health plan is a major plus.  

Key Responsibilities 

Strategic Leadership 

- Lead the development and execution of enterprise-wide strategies for CCM and UM, integrating clinical, behavioral, and social determinants of health (SDoH) interventions. 
- Collaborate with executive leadership to align CCM/UM initiatives with organizational goals, payer contracts, and population health strategies. 

- Create and lead a best-in-class transitional care management program including discharge planning and readmission avoidance program exploring the mix of facility, home and telephonic interventions. 

- Develop and integrate evidence-based MCG clinical guidelines into transitions of care workflows to ensure appropriate length of stay, bed day management, and site of service for acute and post-acute admissions 

-Oversee and responsible for efficient and effective use of the care and utilization management IT platform to drive improved population outcomes. 

- Develop partnerships/programs with other market network providers such as Skilled Nursing Facilities (SNFist), Hospitalists and home care solutions that drive optimal clinical outcomes.  

- Partner with a Chief Medical Officer (CMO) as a dyad partner to implement new clinical and operational protocols designed to drive performance and that help AbsoluteCare meet its key affordability agenda and targets.   

-Experience with health plan delegated care management and utilization management services. 

Program Oversight 

- Direct the implementation of high-intensity, member-centered care models that reduce avoidable utilization and improve quality of life. 
- Ensure compliance with NCQA standards and other regulatory requirements for UM and care coordination services. 

-  Supervises, leads a CM Program Manager, TCM Director, two Clinical Educators, and three centralized Community Team Care Managers (total of 4-7 direct reports). 

Operational Excellence 

- Monitor and optimize care and utilization management workflows, staffing models, and performance metrics across CM and UM teams including bed management, admissions, and ED utilization.  
- Lead the development of efficient and effective clinical training programs, documentation standards, policies and procedures and performance management systems to support clinical and non-clinical staff. 

Team Development 

- Build and mentor a high-performing interdisciplinary team including care managers, behavioral health clinicians, UM nurses, and community health workers. 
- Foster a culture of accountability, innovation, and continuous improvement. 

- Responsible for care manager employee engagement metrics across the company. Responsible to work with site leaders to develop and implement clinical engagement/retetnion action plans that enhance staff satisfaction survey results  

Stakeholder Engagement 

- Serve as a key liaison with payer and health system hospital partners, regulatory bodies, and internal stakeholders to ensure transparency, compliance, and shared success. 

-Develop strong working relationships with market UM/CM leaders, engagement leaders and VPs  that influence optimal clinical engagement AND clinical model execution.  
- Represent the organization in strategic discussions with external partners and at industry forums. 

Qualifications 

- Bachelor’s degree in Nursing, Public Health, Health Administration, or related field required; Master’s degree preferred. 
- Minimum of 10 years in a Senior Director or Vice President role overseeing complex care management, transitional care management or utilization management in a managed care or at-risk value-based medical group environment. 
- Proven track record of leading large-scale, multi-site clinical operations, driving cost savings, achieving affordability targets and improving patient outcomes. 
- Deep understanding of Medicaid/Medicare populations, transitional care management leading to readmission reduction, , and integrated care delivery models. 
- Strong leadership, communication, and change-management skills. 

- Knowledge and experience working with ZeOmega/Jiva electronic health record is a plus, but not required.  

- Must be willing to travel across our different markets to interact with corporate leadership team, managers, and front-line staff.  

Preferred Certifications 

- RN license preferred. 
- Certification in Case Management (CCM), Utilization Review Accreditation Commission (URAC), or related credentials is a plus. 

Why Work at AbsoluteCare?

At AbsoluteCare, we serve the most vulnerable individuals in America. These are our neighbors, people who are at higher risk for disease or who have multiple, complex, chronic illnesses. Often, they deal with an unequal healthcare system and wind up seeking basic care from emergency rooms. We take these patients out of those spaces and turn them into members: people who are entitled to some of the best, most focused care this country has to offer. 

We call this “care beyond medicine.” We have turned the doctor’s office into a comprehensive care center. Here, we surround our members with a core care team of doctors, nurses, social workers, and medical assistants who have the time and skills to get to know our members’ needs. We make the most important services available to our members under one roof. This includes a pharmacy, X-rays, a blood lab, nutrition services, urgent care, and much more.

We don’t stop at our four walls. We engage members in the communities where we all live to find the people who need us most. Through these community care teams, we remove the barriers to healthcare that so many people face daily. And it works. 

Our unique care is guided by our core values of accountability, caring, trust, and teamwork. We call it ACT².

AbsoluteCare, Inc. provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, age, disability, genetics, protected Veteran status, or any other characteristic protected by law or policy.

EEO Employer Verbiage: AbsoluteCare, Inc. provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, age, disability, genetics, protected Veteran status, or any other characteristic protected by law or policy.