Director of Nursing - Utilization Review

NYC Health + HospitalsMetropolitan is the community hospital of choice for residents of East Harlem, northern Manhattan, and neighboring communities. The hospital provides culturally-sensitive care in a welcoming and hospitable setting, emphasizing primary care medicine and utilizing the latest advances in medical science. Metropolitan delivers high quality health services with compassion, dignity, and respect to all, without exception. Since its founding in 1875, the hospital has been affiliated with New York Medical College, representing the oldest partnership between a hospital and a private medical school in the United States. Metropolitan is a part of the NYC Health + Hospitals, the largest municipal hospital and health care system in the country.At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.Job DescriptionInterpret, evaluate and implement NursingPatient Care Services and Hospital Policies and Procedures.Develop and communicate the Metropolitan Hospital Center Utilization Management Plan.Lead the Utilization Management Department including the supervision of daily operations.Manage and evaluate team performance and ensure adherence to department standards.Prepare quarterly H+H Board reports by building and maintaining access databases to analyze denials and appeals.Provide standard and ad hoc reports to monitor progress and guide strategy to prevent denials and increase the reversal rate.Identify issues and patterns which result in potential. Financial loss, (e.g., weak appeals, inefficient processes, payors non-compliance with contracts, etc.) and act to protect revenue.Work collaboratively with hospital administration, and other disciplines to ensure follow-up on utilization issues including but not limited to extended care, alternate level of care meetings.Plan, recommend and work collaboratively in the department to establishing a plan to motivate staff and develop their skills to improve quality of patient care.Apply nursing process to Assess, Plan Evaluate, Implement current and future established hospital wide Quality Assurance Performance Improvement Program and Utilization Management Annual Plan.Participate and support all department staff related to preparation for surveys of various regulatory agencies, and departmental special projects.Act as a patient advocate.Reviews the patient's medical record on admission, during the continued stay and on discharge for appropriateness of documentation.14•.On a concurrent and retrospective review basis, identifies and reports trends and patterns of care, which deviate from standard of care.Collaborate with medical staff nursing and other clinical ancillary staff to clarify issues and initiate corrective action.Minimum Qualifications1. Licensed and currently registered to practice as a Professional Nurse in New York State; and, 2. A Master's Degree in Nursing Administration or an equivalent field, and a minimum of four years of high-level responsible experience in nursing administration, three years of which shall have been in a hospital; or, 3. A satisfactory equivalent. However, all candidates must be licensed and currently registered to practice as a Professional Nurse in New York State.If you wish to apply for this position, please apply online by clicking the "Apply for Job" button. NYC Health and Hospitals offers a competitive benefits package that includes:Comprehensive Health Benefits for employees hired to work 20+ hrs. per weekRetirement Savings and Pension PlansLoan Forgiveness Programs for eligible employeesPaid Holidays and Vacation in accordance with employees' Collectively bargained contractsCollege tuition discounts and professional development opportunitiesMultiple employee discounts programs

Created: 2025-02-23