SUMMARY:
We are currently seeking a Utilization Review Managerto join our Transitional Care Team. This is a full-time management role and will be required to work onsite.
Purpose of this position:Manages the design, development, implementation, and monitoring of utilization review functions. Oversees daily operations, which include supervising staff performing utilization management activities. The goal is to achieve clinical, financial, and utilization goals through effective management, communication, and role modeling. Functions as the internal resource on issues related to the appropriate utilization of resources, coordination of payer communication, and utilization review and management. Responsible for carrying out duties in a manner to assure success in financial management, human resources management, leadership, quality, and operational management objectives. Participates in program development and UR Department performance improvement. Responsible for day-to-day operations of the department, assists with the budgeting process, assists with personnel recruitment, retention, corrective action, and professional development.
RESPONSIBILITIES:
- Participates in the development and management of department budgets and productivity targets
- Directs and manages team of UR Coordinators, promotes employee satisfaction, supports staffdevelopment, and utilizes the progressive discipline process when appropriate
- Collaborates with department director and professional development specialist to develop standardwork and expectations for the utilization review process, including timely medical necessityscreening to ensure patients are placed at the appropriate patient status and level of care,professional communication with physicians and nurses and other members of the care team
- Collaborates with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staffto answer clinical questions related to medical necessity and patient status
- Ensures processes are in place for proactive reviews of surgical and other procedures to confirmaccurate perioperative pre-authorization and patient class order reconciliation process. Assessescompliance to regulatory and health plan requirements for authorization, including Medicare
Inpatient Only List and communicates to provider to obtain accurate order prior to procedure andpost procedure - Ensures UR Coordinators and Clinical Coordinators identify, document, and communicate avoidabledays and delays in services that may prolong length of stay; analyzes data to monitor trends foropportunities to improve services. Partners with hospital Director Transitional Care to reportavoidable days, trends, and actions to UR Committees, as appropriate
- Partners with Physician Advisor to engage in second level review and working with attendingphysicians to document completely to ensure patient class determinations
- Serves as expert resource for all Medicare Notification Letters and ensures appropriate distributionof all letters (IMM, MOON, HINN, etc.) including full documentation to meet regulatory requirementsand ensure correct billing
- Works collaboratively with Inpatient Care Management, Patient Accounting, Patient Admission andRegistration, HIM, and the Finance Department to analyze one-day Medicare inpatient stays andidentify opportunities to improve
- Develops and implements process to manage and respond to all concurrent and post-discharge thirdparty payer denials of outpatient and inpatient cases alleged to be medically inappropriate. Including,but not limited to; Peer-to-Peer as appropriate, written appeal letters when indicated, documentationof interventions and outcomes and monitor to identify opportunities to improve processes for denial
prevention - Serves as the internal expert on documentation and reimbursement requirements. Serves as aresource to the health care team for utilization and denial management. Liaises with provider officestaff and facilitates meetings with payers, as appropriate
- May participate in the Utilization Review Committee to present medical necessity data and outcomesand partners with care management leadership to develop action plans for improvement
- Performs other duties as assigned
QUALIFICATIONS:
Minimum Qualifications:
- Bachelors degree in nursing or related field
- Three to five (3 to 5) years of leadership experience (i.e.,charge nurse, team leader, preceptor, committee chair, etc.)
- Five (5) years clinical experience.
- A minimum of one (1) year of utilization review experience
Preferred Qualifications:
Knowledge/ Skills/ Abilities:
- Ability to deliver financial results for areas of accountability
- Knowledge of or ability to learn financial management related to URfunction and reporting, quality improvement processes, and human
resources management - Able to effectively monitor, evaluate and administer the resources of eachassigned area, and make substantiated recommendations regarding
resource allocation needs for future planning purposes - Able to communicate effectively in writing and verbally, ability to interactwith a wide variety of individuals, and handle complex and confidential
situations - Ability to lead, delegate, analyze information and problem solve
- Demonstrates evidence of strong skills in confidentiality, integrity, creativity,and initiative
License/Certifications:
