Program Manager, Utilization Management

Program Manager, Utilization Management

Program Manager, Utilization Management
Location: United States
Requisition Number1117
Remote?No
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.

Job Summary

The Program Manager, Utilization Management is highly focused on enterprise program development and management of the transitional care program, associated post-acute interventions, and utilization management programs. This includes clinical interventions and guidelines that address appropriate bed day management (observation, acute, sub-acute), emergency department diversion, and other high yield interventions that appropriately reduce utilization of unnecessary healthcare resources. All aimed at reducing preventable admissions/readmissions, complications, and redundant or duplicative healthcare services. This role is a key member of our unique integrated multi-disciplinary team working in collaboration with AbsoluteCare care teams and community healthcare professionals to proactively manage a vulnerable complex population. Programmatic outcomes must adhere to industry standard clinical guidelines (MCG/InterQual), regulatory standards (NCQA), in addition to key performance indicators such as reduction in admissions/bed days, length of stay and total cost of care for our members.

The Program Manager, Utilization Management serves as a transitional care, post-acute and utilization management subject matter expert (SME) across the company for both internal and external facing meetings and initiatives. This role will partner with counterparts on both medical, behavioral and social determinants of health teams to deliver integrated care and ensure relevant interventions are addressing all aspects of our patients' lives. This individual represents the mission, vision, and values of AbsoluteCare at all times.



Education and Experience:

Proven record to lead through change in a dynamic matrixed organization.
Registered Nurse with preferred master’s level degree.
Minimum of 5 years’ experience in transitional care management, post-acute interventions and utilization management programs for complex Medicaid, Medicare, and Dual-Eligible populations.
Experience with transitions of care, discharge planning, inpatient clinical care, and/or robust post-acute programs.
Vast knowledge, successful experience and proven record with care transitions and associated readmission reduction strategies.
Experience with MCG/InterQual criteria for discharge planning and post-acute care management plans.
Proven ability to analyze and leverage population health reporting to identify and successfully implement interventions that led to appropriate utilization and cost reduction.
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.