Director of Clinical Quality and Utilization Management

Company Summary

If you are searching for a fulfilling place to develop your career and an opportunity to make a difference in helping others, then keep reading on. Here at AAC, we have a progressive culture; we listen to your ideas, value a work/life balance, invest in education, and we foster trust and respect for all individuals. Our exceptional comp and strong benefits include company matching 401K, medical, dental, vision and life insurance. We are looking for our future leaders, who are not only going to fill the qualifications for this job description, but who are going to exceed expectations. Be a part of a team whose mission is to provide quality, compassionate, and innovative care to adults struggling with addiction and co-occurring mental health disorders. Our purpose and passion are to empower patients, their families, and our communities by helping individuals achieve recovery and optimal wellness of the mind, body, and spirit.

Job Summary

The National Utilization and Clinical Quality Director is responsible for ensuring that treatment services are documented in a clear and concise manner and follow cost-effective UR practices. This position is responsible for leading company-wide documentation performance and quality improvement as well as UR oversight. The National Utilization and Clinical Quality Director will work to improve qualitative documentation practices, UR processes, auditing systems, and documentation outcomes. This position will examine each facility's documentation and UR practices and is responsible for analyzing clinical teams' data regarding payor feedback from denials, prepayment reviews, and audits. The Director of Clinical Quality and Utilization Management is responsible for providing oversight and management regarding payor audits, qualitative content management, insurance payor guidelines, UR processes, and medical necessity requirements to support billing. 

Duties and Responsibilities:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.

The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Collaborate closely with executive team and National Director of Clinical Quality to develop/improve infrastructure needed to support quality improvements;
• Monitor program RCAs and participate as needed;
• Develop and launch PI initiatives and developing supporting policy and procedures, such as utilizing PDSA model to improve patient experience and SOC;
• Work with facility IRs and monitor and address safety concerns;
• Work closely with Senior Data Analyst in Power BI (Clinical Scorecard Builds) to edit and align metrics;
• Preforms Power BI “drills downs” and monitors data;
• Tracks and trends data for reports and implementation of facility performance improvement based on scorecard;
• Building/creating forms as needed;
• Manages accreditation requirements, supporting facilities maintenance of survey readiness, preparation, synchronize and harmonize accreditation plans between facilities when applicable;
• Ongoing monitoring of Power BI Clinical Scorecard and work with program stakeholders in support of meeting established standards of care;
• Draft and development of Policy and Procedures as needed;
• Provide support and training to facility as needed,
• Oversee and direct facilities efforts for performance and quality improvements systems, and risk management, as well as:
• Clinical Quality
  • Performance Improvement Initiatives
  • Monitor facilities Quantitative documentation and performance
  • Support facilities with accreditation changes and updates
  • Monitor Monthly scorecards and follow up with facilities for performance improvement
• Review and monitor critical incidents and follow up with program stakeholders for staff education, training and progressive discipline for appropriate follow up and closure of critical incidents;
• Other program driven initiatives such as:
  • Time Management Reports (workload/work volume v ADC)
  • CSAT Completion & Score
  • Outcome measurements
  • Daily billing reports
• Lead the development with program stakeholder any necessary Root Cause Analysis and follow up on identified corrective action plans;
• Abide by the standards of HIPAA and 42 CFR Part 2 guidelines;
• Maintain upkeep of personal professional licensing and/or certification, and CEU’s as required by state boards without lapse, holds, suspensions, or investigation.

Education/Experience:

• Bachelors degree in nursing preferred or certification in healthcare quality management 
• Required 2-years minimum experience in UR management within the substance abuse or behavioral healthcare industry. 
• Current knowledge of state and federal regulations, UR processes, payor guidelines, and billing practices for SUD treatment. 
• Experience working with payor prepayment reviews, audits, and reimbursement denials for behavioral healthcare facilities. 
• Strong organizational and leadership skills. 
• If in personal recovery, a minimum of 2 years clean and sober.

Physical Requirements

“AAC is committed to principles of equal opportunities for all employees.  The Company will provide reasonable accommodations that are necessary to comply with State and Federal disability discrimination laws”.  

• Ability to sit, use hands and fingers, talk or hear, and smell continually.  Ability to stand, walk and reach frequently. Ability to climb or balance, stoop, kneel, or crouch occasionally.
• Ability to frequently lift and carry up to 10 lbs. and occasionally lift and carry up to 25 lbs.
• Close vision required to see computer monitor, read documents, and operate copy and fax machine.  Distance vision required to drive an automobile, if driving is a requirement of the job.
• Work environment is indoors and climate controlled.  Occasionally exposed to outdoor weather conditions.
• Moderate noise levels as found in a business office with computer printers, households with TVs and dishwashers, and driving light traffic.

 Certificates and Licenses:

• Certified Professional in Healthcare Quality (CHC or CPHQ or equivalent) required

 Other Work Requirements:

• Must have excellent communication skills (written and verbal), interpersonal skills, project management and organizational skills
• Proficient MS Word, Excel, Outlook, and PowerPoint
• Working knowledge of Lean Six Sigma/Lean
• Population health management and/or clinical quality program development experience preferred
• Experience with Quality Improvement and Corrective Action plans
• Experience working with private health insurance payors
• Strong strategic thinking and analytical skills; excellent organizational, presentation, and problem solving skills
• Candidate must be task and project-oriented with an excellent sense of priority, logic and objectivity.
• Possible travel as needed

American Addiction Centers is an equal opportunity employer.  American Addiction Centers prohibits employment practices that discriminate against individuals or groups of employees on the basis of age, color disability, national origin, race, religion, sex, sexual orientation, pregnancy, veteran or military status, genetic information or any other category deemed protected by state and/or federal law.