The Senior Director, Complex Care Management (CCM) and Utilization Management (UM) is a strategic senior leader position that is responsible for designing, implementing, and optimizing integrated care delivery models that improve health outcomes for medically and socially complex populations. This role oversees the national CCM and UM programs, ensuring alignment with at-risk value-based care principles, transitional care management, regulatory compliance, and operational excellence across all markets. Experience with delegated care management and/or utilization management from a health plan is a major plus.
Key Responsibilities
Strategic Leadership
- Lead the development and execution of enterprise-wide strategies for CCM and UM, integrating clinical, behavioral, and social determinants of health (SDoH) interventions.
- Collaborate with executive leadership to align CCM/UM initiatives with organizational goals, payer contracts, and population health strategies.
- Create and lead a best-in-class transitional care management program including discharge planning and readmission avoidance program exploring the mix of facility, home and telephonic interventions.
- Develop and integrate evidence-based MCG clinical guidelines into transitions of care workflows to ensure appropriate length of stay, bed day management, and site of service for acute and post-acute admissions
-Oversee and responsible for efficient and effective use of the care and utilization management IT platform to drive improved population outcomes.
- Develop partnerships/programs with other market network providers such as Skilled Nursing Facilities (SNFist), Hospitalists and home care solutions that drive optimal clinical outcomes.
- Partner with a Chief Medical Officer (CMO) as a dyad partner to implement new clinical and operational protocols designed to drive performance and that help AbsoluteCare meet its key affordability agenda and targets.
-Experience with health plan delegated care management and utilization management services.
Program Oversight
- Direct the implementation of high-intensity, member-centered care models that reduce avoidable utilization and improve quality of life.
- Ensure compliance with NCQA standards and other regulatory requirements for UM and care coordination services.
- Supervises, leads a CM Program Manager, TCM Director, two Clinical Educators, and three centralized Community Team Care Managers (total of 4-7 direct reports).
Operational Excellence
- Monitor and optimize care and utilization management workflows, staffing models, and performance metrics across CM and UM teams including bed management, admissions, and ED utilization.
- Lead the development of efficient and effective clinical training programs, documentation standards, policies and procedures and performance management systems to support clinical and non-clinical staff.
Team Development
- Build and mentor a high-performing interdisciplinary team including care managers, behavioral health clinicians, UM nurses, and community health workers.
- Foster a culture of accountability, innovation, and continuous improvement.
- Responsible for care manager employee engagement metrics across the company.Responsible to work with site leaders to develop and implement clinical engagement/retetnion action plans that enhance staff satisfaction survey results
Stakeholder Engagement
- Serve as a key liaison with payer and health system hospital partners, regulatory bodies, and internal stakeholders to ensure transparency, compliance, and shared success.
-Develop strong working relationships with market UM/CM leaders, engagement leaders and VPs that influence optimal clinical engagement AND clinical model execution.
- Represent the organization in strategic discussions with external partners and at industry forums.
Qualifications
- Bachelor’s degree in Nursing, Public Health, Health Administration, or related field required; Master’s degree preferred.
- Minimum of 10 years in a Senior Director or Vice President role overseeing complex care management, transitional care management or utilization management in a managed care or at-risk value-based medical group environment.
- Proven track record of leading large-scale, multi-site clinical operations, driving cost savings, achieving affordability targets and improving patient outcomes.
- Deep understanding of Medicaid/Medicare populations, transitional care management leading to readmission reduction, , and integrated care delivery models.
- Strong leadership, communication, and change-management skills.
- Knowledge and experience working with ZeOmega/Jiva electronic health record is a plus, but not required.
- Must be willing to travel across our different markets to interact with corporate leadership team, managers, and front-line staff.
Preferred Certifications
- RN license preferred.
- Certification in Case Management (CCM), Utilization Review Accreditation Commission (URAC), or related credentials is a plus.
We are passionate about our work and compassionate toward our people, whether they work here or seek care from us.
We opened the first AbsoluteCare center in Atlanta in 2000, with a primary focus on treating members with HIV/AIDS. We quickly became an HIV Center of Excellence, achieving impressive results: an 88 percent retention rate and a 97 percent undetectable rate.
A surprising thing happened. With so many of them free of the symptoms of HIV/AIDS, our members sought primary care from us. They were coming in for help controlling asthma, diabetes, heart disease, hypertension, and all the other conditions that life and aging had thrown their way.
So we transformed. We assembled a larger team of qualified, passionate practitioners to offer whole-life care in a new, larger center. And in the last two decades, we have expanded our facilities to multiple locations in several states, where we offer our members everything from primary care to nutrition counseling, behavioral health, and life services.
The members who set foot in an AbsoluteCare center are usually underserved. With their health already compromised, life’s daily stressors add to their level of need.
