Utilization Management Program Lead
Who We Are:
At Cityblock Health, our mission is to radically improve the health of urban communities, block by block. We integrate services to address physical, behavioral, and social needs together, delivered at community hubs and through field-based care teams to make healthcare more accessible, supportive and goal-driven for the people who need it most.
Every aspect of the Cityblock Health care model is carefully designed to focus on our members, engaging and empowering them to own and improve their health through trusted relationships. Through mobile interdisciplinary care teams, we are flexible in how we deliver care, meeting members where they are, and together developing and working longitudinally through a personalized and integrated Member Action Plan (MAP). The care team collaborates to support each member’s whole health and social needs. Enabled by custom-built technology, we build capacity, deliver care and dramatically change members’ opportunities and outcomes.
Partnering with community-based organizations and well-respected health plans, and backed by some of the top healthcare investors in the country, we are reorganizing the health system to focus on what matters to our members—and leading the move from transactional, fee-for-service medicine towards high-value, relationship-based partnerships.
As the Utilization Management Program leader, you’ll build Cityblock Health’s utilization management function and lead us through the regulatory certification process. You will work cross-functionally with our product and clinical areas to build out policies, processes and supporting technology capabilities that will support implementation of a fully delegated utilization management program. You will define the staffing needs of the function and work with operations and talent acquisition associates to hire and train the team needed to launch the program. You will also manage the life-cycle of the health plan delegation process from the pre-delegation assessment to on-going management and reviews/audits. As we scale to new markets and partner with more health plans, you will lead policy development, reporting, and quality improvement strategies that ensure Cityblock remains compliant with state, federal and NCQA regulations. You’ll work cross-functionally across our Clinical, Operations, Data and Product teams to optimize the utilization management program. You will be the primary point of contact for our partner UM Delegation Oversight Committees, ensuring all SLA requirements are met, corrective action plans are completed, and new requirements are implemented within our UM procedures.
- Define scope and then build the policies, processes and procedures underpinning the Cityblock Health Utilization Management function
- Define technology and platform requirements to support the function, and lead identification of solutions to meet those needs
- Lead the certification process for gaining national certification (e.g., URAC, NCQA)
- Define a staffing model and then recruit the associates required to support and grow the function
- Create and maintain accurate, complete written policies and procedures for all regulatorily required utilization management and medical policies
- Define and implement audit programs that ensure that Cityblock proactively identifies and implements solutions (at the employee, hub/clinic, regional or national level) to audit findings
- Oversee and manage all utilization management delegation reporting and audit preparations
- Train internal clinical and operations staff on UM processes and compliance
- Work cross-functionally across the clinical, operations, data and product teams to ensure that needed regulatory technology, operations and data requirements are documented, prioritized, implemented and trained
- Partner with compliance to ensure that the UM program is administered and controlled in a compliant manner with continual scanning for risk and remediation of any risks, fraud, waste or abuse identified
- Act as the primary point of contact and business owner with the utilization management delegation lead counterpart at Cityblock Health health plan partners
- Lead the delegation oversight committee meetings with our health plan partners as the Cityblock representative
- Maintain expert knowledge of current and ongoing updates, revisions, modifications or changes in federal or state statutes, regulations and mandates and partner-specific requirements -- and lead implementation of changes within Cityblock as a result of changes to these rules and regulations
- Be responsible for creating and maintaining accurate, complete written policies and procedures with respect to Cityblock and any subcontractor obligations and responsibilities
You’d be a good fit if:
- You have at least 5+ years experience building, growing and leading a utilization management function at a health plan, delegated health care delivery organization (health system or medical group) or delegated UM vendor
- You are an RN with an active clinical license
- You have a deep understanding and love of the value utilization management provides within an integrated, coordinated care delivery model
- You like and want to build a UM program from scratch
- You have a good understanding of technology/product requirements and data needs for an excellent UM program
- You have clinical operations experience
- You work well with clinicians and other stakeholders across healthcare settings to roll-out projects
- You have good project management abilities
- You can effectively collaborate with senior leaders at a health plan partner to articulate Cityblock’s utilization management policies, processes and compliance
Nice to have:
- You have worked within a capitated clinical delivery system
You should include these in your application:
- A resume and/or LinkedIn profile.
- A 1-2 paragraph response indicating why this job is compelling to you.
Cityblock values diversity as a core tenet of the work we do and populations we serve. We are an equal opportunity employer, indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.