Utilization Management Director Sample Clauses

The Utilization Management Director clause designates an individual or role responsible for overseeing and managing the use of healthcare services within an organization or under a specific agreement. This clause typically outlines the authority of the Utilization Management Director to review, approve, or deny requests for medical services, ensuring that care provided is medically necessary and cost-effective. By clearly assigning these responsibilities, the clause helps streamline decision-making processes and ensures that resource utilization aligns with organizational policies and regulatory requirements.
Utilization Management Director. The Utilization Management Director must: Be an Ohio-licensed registered nurse or a physician with a current unencumbered license through the Ohio State Medical Board with experience in the activities of utilization management, in accordance with 42 CFR 438.210; Preferably be certified as a Certified Professional in Health Care Quality by the NAHQ and/or CHCQM by the American Board of Quality Assurance and Utilization Review Providers; and The Utilization Management Director's primary responsibilities are to: Oversee the day-to-day operational activities of the Utilization Management Program in accordance with state guidelines; Develop written policies and procedures regarding authorization of services and monitor to ensure that these are followed; Ensure the consistent application of review criteria for authorization decisions; Ensure that decisions to deny or reduce the amount of services are made by a health care professional who has appropriate clinical expertise in treating the member's condition or disease; Ensure MCO Notices of Adverse Action are provided in accordance with 42 CFR 438.404; Ensure that all authorization decisions are made within the specified allowable timeframes; and Evaluate under and over utilization information for impact on member quality of care and outcomes, including access to care.
View SourceView Similar (4)
Utilization Management Director. The Utilization Management Director must:
View SourceView Similar (2)
Utilization Management Director. One full-time employee. 4.2.11.1.6. 1. The Utilization Management Director shall: 4.2.11.1.6.1.1. Lead and develop the utilization management program and manage the medical review and authorization process. 4.2.11.1.6.1.2. Oversee the medical appropriateness and necessity of services provided to Members. 4.2.11.1.6. 1.3. Analyze and monitor utilization trends, identify problem areas and recommend action plans for resolution.
View SourceView Similar (2)
Utilization Management Director. 1. The Utilization Management Director must: Be an Ohio-licensed registered nurse, APRN, licensed independent behavioral health clinician (MD, DO, RN with Advance Practice Registered Nurse [APRN] licensure, psychologist, licensed independent social worker [LISW], professional clinical counselor [LPCC], independent marriage and family therapist [LIMFT]) with a current unencumbered license through the Ohio State Medical Board with experience in the activities of utilization management, in accordance with 42 CFR 438.210. The Utilization Management Director must have at least three years' experience providing direct behavioral health care coordination or oversight for children and adolescents with complex behavioral health needs; Preferably be certified as a Certified Professional in Health Care Quality by the NAHQ or CHCQM by the American Board of Quality Assurance and Utilization Review Providers; and The Utilization Management director can be located out of state if prior approved by ODM. Upon ODM approval, any out of state Utilization Management Director hire must meet Ohio licensing requirements within 6 months of hire. 2. The Utilization Management Director's primary responsibilities are to: Oversee the day-to-day operational activities of the Utilization Management Program in accordance with state guidelines; Develop written policies and procedures regarding authorization of services and monitor to ensure that these are followed; Ensure the consistent application of review criteria for authorization decisions; Collaborate with OhioRISE Plan's clinical leadership to implement the Utilization Management Program in a manner reflective of the roles and responsibilities of the CFT; Ensure that decisions to deny or reduce the amount of services are made by a health care professional who has appropriate clinical expertise in treating the member's condition or disease; Ensure OhioRISE Plan's Notices of Adverse Action are provided in accordance with 42 CFR 438.404; Ensure that all authorization decisions are made within the specified allowable timeframes; and Evaluate under and over utilization information for impact on member quality of care and outcomes, including access to care.
View Source
Utilization Management Director 
View SourceView Similar (2)

Related to Utilization Management Director

  • Utilization Management Contractor shall maintain a utilization management program that complies with applicable laws, rules and regulations, including Health and Safety Code § 1367.01 and other requirements established by the applicable State Regulators responsible for oversight of Contractor.

  • Union/Management Committee There shall be a union/management committee comprised of four (4) employee representatives appointed by the Union and four (4) employer representatives. The Committee's purpose is to provide and promote effective and meaningful communication of information and ideas and to make joint recommendations on matters of concern. Matters that are properly the subject of an individual grievance will not be discussed at this committee. The Committee will meet quarterly, unless agreed otherwise, at a time and place mutually agreed to provided there is business for their joint consideration. The parties will exchange agenda items at least one (1) week prior to the meeting. The parties further agree the Committee may meet at any time its members mutually agree a meeting should be held. The duties of the Chairperson will be shared by the parties. Copies of the minutes shall be provided to Committee members. The employer agrees to pay for time spent during regular working hours for representatives of the union attending such meetings. The parties may utilize video or teleconferencing services for the purposes of committee members attending committee meetings, where appropriate and available. Neither party can unreasonably deny an initiative to utilize video or teleconferencing services.

  • Project Director The individual designated by the juvenile board or Chief Administrative Officer, who is to be responsible for the administration and coordination of grant funds in accordance with this Contract ,, the general grant requirements, and applicable Targeted Grant requirements.

  • Labour Management Relations Committee In recognition of the mutual benefits of open communications and on-going consultation between the faculty and the employer, the Labour/Management Relations Committee will meet on a regular basis and have equal representation for the Union and the Employer. The LMRC will serve as an open forum for the free and candid discussion of matters of mutual concern to faculty members and management.

  • EMPLOYEE-MANAGEMENT ADVISORY COMMITTEE 10.01 The Parties to this Collective Agreement agree to establish Employee-Management Advisory Committee(s) (EMAC) within the sites. Each Committee will consist of a maximum of six (6) persons with equal representation from the Parties. 10.02 In a site that has an established mechanism(s) that performs the functions of the EMAC as described in Clause 10.08 and where the mechanism(s) provides for the representation from this bargaining unit then the Employer and the Union Representative may mutually agree to waive Clause 10.01. 10.03 The representatives of the Employer on EMAC shall be those persons or alternates employed and designated by the Employer from time-to-time. 10.04 The representatives of the Union on EMAC shall be those Employees or Employee alternates designated by the Local from time-to-time. 10.05 The Parties mutually agree that the representatives of the Employer and the Union on EMAC should be the persons in authority whose membership should be as constant as reasonably possible with a minimum of alteration or substitution. 10.06 The Chair on EMAC shall be the senior representative of the Employer, and the Vice-Chair shall be the senior representative of the Union. 10.07 EMAC shall meet at a mutually acceptable hour and date. Either the Chair or the Vice-Chair may mutually call a special meeting to deal with urgent matters. 10.08 It is the function of EMAC to consider matters of mutual concern affecting the relationship of the Employer to its Employees and to advise and make recommendations to the Employer and the Union with a view to resolving difficulties and promoting harmonious relations between the Employer and its Employees. Zone matters of mutual concern may be referred to the Joint Task Force. 10.09 Either the Employer or the Union may have experts or advisors present at meetings of EMAC to make submissions to or to assist EMAC in the consideration of any specific problem. Each Party shall give the other reasonable advance notice of the anticipated presence of such experts or advisors. 10.10 Where an EMAC has not been established within a site, the Union may request a meeting with the designated Human Resources Department to discuss the formation of EMAC(s). 10.11 Within thirty (30) days of the request, the Parties will meet to discuss membership and subsequent development of Terms of Reference in accordance with Article 10: Employee Management Advisory Committee. (a) Every effort will be made by the Parties to schedule this Committee meeting during an appointed Employee’s regular working hours; and (b) In continuous operations, when (i) an Employee is not scheduled to work; and (ii) it is not possible to schedule the meetings during a time when the Employee is scheduled to work; and (iii) no alternate attendee is available or appropriate to attend, an Employee who attends a EMAC meeting shall be paid at the basic hourly rate of pay. 10.13 Time spent in meetings of this Committee (inclusive of travel time) during an Employee’s scheduled working hours shall be considered time worked and the Basic Rate of Pay will be paid to such Employees. 10.14 Where applicable, an Employee shall be entitled to claim travel time expenses in accordance with Article 38: Transportation and Subsistence.