Director, Utilization Management

Evolent Health, Inc. Louisville , KY 40202

Posted 7 months ago

It's Time For A Change

Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.

Are we growing? Absolutely56.7% in year-over-year revenue growth in 2016. Are we recognized? Definitely. We have been named one of "Becker's 150 Great Places to Work in Healthcare" in 2016 and 2017, and one of the "50 Great Places to Work" in 2017 by Washingtonian, and our CEO was number one on Glassdoor's 2015 Highest-Rated CEOs for Small and Medium Companies. If you're looking for a place where your work can be personally and professionally rewarding, don't just join a company with a mission. Join a mission with a company behind it.

What You'll Be Doing:

This role is responsible for overall management of the activities relating to the strategy, tactics, policies, and programs that drive utilization for plan sponsor network providers and members. This is a critical role in the growing Evolent Health organization in that it will be responsible for developing out new capabilities within Evolent Health and in working closely with partner organization to develop efficient and effective programs that achieve cost and quality goals in a way that is integrated into the local delivery system.

  • Monitoring the utilization management of resources of client network and implementation of initiatives and educational processes to achieve targeted utilization management results established by the client;

  • Developing systems and processes for the assumption of utilization management responsibilities by the provider network to create alignment and accountability.

  • Responsible for overall direction of activities related to medical review; development of on-site processes where indicated; and telephonic review process of all necessary utilization management components;

  • Monitoring the timeliness and accuracy of utilization management data and reporting to meet requirements of applicable regulatory agencies;

  • Development and implementation of appropriate utilization management programs and policies;

  • Leadership of utilization management activities including design, and implementation of Utilization Management Program Description goals and related activities.

  • Responsible for ensuring rigorous, consistent, and disciplined design and execution of integration with the Evolent Health Quality Management program

  • Using data analysis to identify opportunities for quality improvement;

  • Developing and adopting best practice methodologies and training programs for utilization management tools and techniques;

  • Responsible for directing activities related to special projects for utilization management and use of project resources.

  • Development of budgets, staffing plans, and assuring adequate allocation of resources;

  • Assisting to build utilization management initiatives and tools to support Evolent Health and its partners in constant expansion;

  • Responsible for developing business requirements in collaboration with the IT and analytics teams for the development of required utilization management monitoring, predictive modeling initiatives, patient engagement and other outcomes initiatives;

  • Enhancing relationships with providers, facilities, plan sponsors, clients, regulatory agencies, and partners.

  • Responsible for monitoring member and provider satisfaction survey results and creating necessary changes where indicated.

  • Working collaboratively with other functional areas that interface with the utilization management department including provider services, member services, benefits, claims management, contracting, healthcare and medical delivery services.

  • Responsible for providing appropriate, timely management of complex clinical issues.

  • Mentoring employees and supporting ongoing training and development of staff.

  • Promoting a positive work environment by providing timely, specific and constructive performance feedback.

The Experience You'll Need:

  • Five to ten years of progressive experience in utilization management and/or healthcare financing.

  • Bachelor's Degree in Nursing (with Masters in Nursing, Business Administration/Hospital Administration/ Public Health strongly preferred.)

  • Active license as Registered Nurse (RN, RNC).

  • Experience working within a provider owned health plan or a risk bearing provider organization preferred;

  • Ability to effectively and persuasively communicate at all levels of the organization.

  • Demonstrated ability to collaborate with and influence others and resolve conflict.

  • Strong organizational and project management skills.

  • Demonstrated ability to drive and deliver results.

  • Ability to travel to customer and prospect sites.

Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.


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Director, Utilization Management

Evolent Health, Inc.