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AmeriHealth Caritas Corporate Director Utilization Management Operations in Philadelphia, Pennsylvania

Corporate Director Utilization Management Operations

Location: Philadelphia, PA

Primary Job Function: Medical Management

ID**: 19215

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at .


Under the general direction of the VP UM Operations, the Corporate Director of Utilization Management Operations is responsible for the successful, ongoing development, refinement, implementation, measurement, ongoing quality improvement and effectiveness of the enterprise Utilization Management Program. This leader will be responsible for new business RFPs and implementations, The Director UM operations will identify opportunities for next best actions to improve processes and lower costs. This leader will apply expertise in developing and utilizing key performance indicators to identify and investigate complex problems in various health care domains across several problem spaces. This leader will also deliver results on high-impact projects collaborating with various stake holders.

A successful leader will perform well in a fast-paced environment, will have an operational mindset with attention to detail, and will focus on identifying value to challenging business problems. This position requires strong business acumen, exceptional communication skills, and the ability to make complex concepts simple and easy to understand.

This includes the following:

  • Concurrent review of acute, skilled and rehabilitation inpatient episodes, prior authorization of elective, inpatient and outpatient procedures and durable medical equipment requiring pre-certification and processing of medical necessity appeals.

  • Functional support to the each market’s Network Management, Informatics, Information Solutions, Quality Management, Care Coordination, and Public Affairs departments to integrate Utilization Management initiatives and goals with organizational programs.

  • Active role in the dissemination of best practices throughout the AmeriHealth Family of Companies and assists with new business opportunities and implementation.

  • Ensures consistency and conformance to all applicable standards and regulations.

  • Ensures UM operational processes are meeting contractual time lines and SLEa.

  • Oversee effective use of prior authorizations, policies, and benefits to ensure consistent, effective and efficient delivery to members while meeting regulations and internal financial objectives.

  • Review periodic reports (financial/utilization/services) to analyze trends, identify opportunities and ensure consistent deployment of accurate data according to established polices & procedures across enterprise and market teams.

  • Initiates organizational and system changes to improve departmental staffing efficiency and effectiveness, and program outcomes within the markets.

  • Monitors performance metrics across LOBs and assures that appropriate action is taken to address performance opportunities consistent with enterprise policies.

Education/ Experience:

  • Bachelor’s Degree in Healthcare related field required.

  • RN Preferred.

  • 5 to 10 years Clinical experience, leading and managing UM teams required.

  • 3 to 5 years managed care experience required.

EOE Minorities/Females/Protected Veterans/Disabled