SWHRCIN VP Utilization Mgt SWHR CIN at Southwestern Health Resources CIN in Pittston, Pennsylvania

Job Description:

Southwestern Health Resources, which blends the strengths of University of Texas Southwestern Medical Center and Texas Health Resources, includes a clinically integrated network of 29 hospital locations and more than 5,000 providers, committed to being the national leader in population health.

SWHR is transforming population health by harnessing machine learning platforms and developing leading predictive analytics that set national standards. With more than 650 points of access to care, this provides for higher value and allows patients to access services across a full continuum of medical needs. The network serves people across 17 counties in North Texas. In total, Southwestern Health coordinates care for more than 700,000 patients, aligned with commercial health care plans and Medicare programs. SWHR operates the nation's highest rated Next Generation Accountable Care Organization.

The Vice President, Utilization Management and Effectiveness, is responsible for providing leadership and direction for utilization management operations. The VP will lead the design, implementation and delivery of key strategies aimed at ensuring consistent, efficient and impactful UM programs.

Responsibilities and Duties:

• Develop comprehensive strategy to position SWHR as a leader in utilization management and effectiveness, including pre-service, concurrent post-service reviews and transitions of care, for all delegated risk contracts. • Lead ROI strategic UM and UE initiatives, including business case development, network capability and readiness, vendor assessment and selection, contracting, implementation and monitoring. • Lead program development to support changes in the market, contractual relationships and organizational needs. • Collaborate internally and externally to the organization to develop and implement organizational UM service delivery opportunities. • Drive clinical services through the development of facility and provider relationships and engagement in community joint operations. • Oversee the utilization management delegation, ensuring that the UM program meets all regulatory requirements as set forth by the delegation agreements and NCQA standards, including regulatory reporting requirements. Works closely with Compliance. • Working with Compliance, manage all delegation audits and lead all corrective actions stemming from any audits. • Identify key utilization trends that could impact the Organization's financial and/or operational performance. Ensure routine assessment of all metrics measured support internal and external factors that could affect performance. • Manage UM departmental budget, including reporting benefits and costs to Executive Team. • Performs other duties as assigned.

Professional Experience/Qualifications:

Individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individual with disabilities to perform the essential functions. This role requires the ability to solve problems, think outside-the-box, and be resourceful; must be result-oriented, a quick learner and self-starter. Comfortable working in complex and matrix organizations. The requirements listed below are representative of the knowledge, skill, and/or ability required to build SWHR's culture for action.

• Bachelor's degree from accredited college in Nursing, Healthcare Administration or Related Field required. • RN or NP with current Texas License required • Master's Degree from accredited college in Business or Healthcare preferred. • 10 years' related experience in case management, utilization review, and/or medical management required. • 5 years' experience in management, preferably in complex, matrixed organizations required. • Broad understanding of UM and associated NCQA accreditation standards • Experience in case management and utilization reviews • Knowledge of ACO financial models, health care delivery systems and market dynamics. • Strong data analytic skills • Ability to monitor and maintain a budget. • Ability to effectively interpret and apply organizational policies, procedures, and systems. • Excellent interpersonal, organizational, supervisory/managerial, and analytical skills. • Demonstrated ability to manage multiple projects and exercise independently decision-making and problem-solving skills • Ability to lead committees • Proficient in Microsoft Office (Excel, Word, PowerPoint)