Point C is a National third-party administrator (TPA) with local market presence that delivers customized self-funded benefit programs. Our commitment and partnership means thinking beyond the typical solutions in the market – to do more for clients – and take them beyond the standard “Point A to Point B.” We have researched the most effective cost containment strategies and are driving down the cost of plans with innovative solutions such as, network and payment integrity, pharmacy benefits and care management. There are many companies with a mission. We are a mission with a company.
The Director of Utilization Management (UM) is responsible for overseeing and managing the processing of all pre-certification services to ensure reviews are conducted within URAC HUM and quality standards. This role provides leadership to the UM team, ensures compliance with regulatory requirements, and supports high-quality, cost-effective patient care through appropriate utilization of services.
Primary Responsibilities
Oversee prospective, concurrent, and retrospective medical necessity reviews for specific services
Ensure timely and accurate communication with physicians, hospitals, and patients
Manage documentation and data entry within pre-certification systems to ensure accurate claim adjudication
Review and respond to requests for additional information, including medical records and letters of medical necessity
Approve appropriate levels of care, including extended length of stay, care transitions, and discharge planning
Monitor regulatory turnaround times and collaborate with Care Coordination to ensure proper case escalation
Provide leadership and direction to UM staff, including UM Processors, Workflow Administrators, and Review Specialists
Partner with internal leaders and the Medical Director on UM processes, escalations, and outcomes
Perform other duties as assigned
Qualifications
Active RN license (required)
High school diploma or equivalent; bachelor’s degree in nursing or related field preferred
3+ years of experience in Utilization Management
Proficiency in medical terminology and coding
Strong leadership, critical thinking, and time management skills with the ability to maintain a high level of professionalism
Individual compensation will be commensurate with the candidate's experience and qualifications. Certain roles may be eligible for additional compensation, including bonuses, and merit increases. Additionally, certain roles have the opportunity to receive sales commissions that are based on the terms of the sales commission plan applicable to the role.
- Comprehensive medical, dental, vision, and life insurance coverage
- 401(k) retirement plan with employer match
- Health Savings Account (HSA) & Flexible Spending Accounts (FSAs)
- Paid time off (PTO) and disability leave
- Employee Assistance Program (EAP)
Equal Employment Opportunity: At Point C Health, we know we are better together. We value, respect, and protect the uniqueness each of us brings. Innovation flourishes by including all voices and makes our business—and our society—stronger. Point C Health is an equal opportunity employer and we are committed to providing equal opportunity in all of our employment practices, including selection, hiring, performance management, promotion, transfer, compensation, benefits, education, training, social, and recreational activities to all persons regardless of race, religious creed, color, national origin, ancestry, physical disability, mental disability, genetic information, pregnancy, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, and military and veteran status, or any other protected status protected by local, state or federal law.
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