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The French Group has been retained by our client, a highly-regarded, patient-centric care management organization, to fill this highly visible senior role. 



The Director will report to the Chief Operating Officer and will collaborate with other senior leaders in the Payor Services Group. She/he will be accountable for developing and implementing the case and utilization management programs with a multidisciplinary approach.  Key responsibilities include oversight of the case and utilization management program and ensuring the health plan’s programs are compliant with URAC, or general accreditation standards, as well as, State and federal regulatory requirements. The ideal candidate is a well-spoken, enthusiastic and organized person with the ability to work productively and confidently with team members, patients, providers and clients.



  • Design, develop and implement a comprehensive case and utilization management strategy for the      organization
  • Develop systems and processes for prospective, concurrent and retrospective utilization review
  • Collect, analyze and maintain data regarding utilization of medical services
  • Identify, investigate and educate providers who are outliers in terms of medical practice
  • Oversee the identification, tracking, resolution and response to all denials and appeals in compliance with URAC or general accreditation standards
  • Represent the company at external meetings with provider groups to address issues, improve      communication and educate providers regarding the health plan’s utilization management process
  • Ensure that there are appropriate policies and procedures in place to support all utilization management and case management activities
  • Ensure that all department activities are in compliance with URAC or general accreditation standards,      as well as state and federal regulatory requirements
  • Prepare monthly and quarterly utilization management reports for submission
  • Maintain strict confidentiality of employee and organizational information in accordance      with HIPAA and State privacy regulations
  • Provides clinical guidance and supervision to all case management programs, based on accepted      principles of nursing and case management practice
  • Provides clinical perspective and best practices to staff through one-on-one coaching, group interaction, in-service training, and other team meetings
  • Manages a staff of nurses and monitors department activities to evaluate the productivity and quality of programs and processes in order to identify potential improvements and to ensure maximum performance
  • Develops, manages and participates in departmental projects, workflow processes, policies and procedures in collaboration with internal and external stakeholders
  • Collaborates with staff and leadership to develop and implement systems that support operations and business goals within identified areas of responsibility
  • Maintains professional and clinical relationships with stakeholders; regularly discussing any concerns regarding utilization of services or complicated cases
  • Uses a collaborative approach with the case management team in order to revise, develop, and implement cost savings methodologies and interventions
  • Facilitates communication with providers to ensure continuity of care and coordination between multiple specialists, providers, and vendors



  • Bachelor’s degree in nursing is required.
  • Current state license as a Registered Nurse is required.
  • Three years or more of experience in managing a case and utilization management program
  • Knowledge of URAC or general accreditation standards preferred
  • Knowledge of health care utilization management processes and documentation
  • Knowledge of authorizations and claims data
  • Experience in healthcare utilization data analysis for the identification of cost savings
  • Excellent written, verbal and presentation skills
  • Excellent interpersonal skills
  • Strong analytical and data interpretation skills
  • Ability to work cooperatively with peers and subordinates
  • Ability to motivate others toward achievement of common goals
  • Ability to think creatively to resolve common barriers and issues



Tricia French RN, BSN

President & CEO

The French Group