Market Director Utilization Management

Overview CHI Saint Joseph Health supports 5000 active employees 8 hospitals specialty clinics and a Medical Group with more than 200 locations across Central and Eastern KY. CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health in 2019. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community. Responsibilities The Utilization Management (UM) Director is responsible for the market(s) development, implementation, evaluation and direction of the Utilization Management Program and staff in support of the CommonSpirit Health Care Coordination model.  The Utilization Management department processes authorizations, inpatient admission and continued stay reviews, retrospective authorizations utilizing standardized criteria to determine medical necessity; reviews and processes concurrent denials that require medical necessity determinations; processes appeals and reconsiderations. In collaboration with the Division Director Care Coordination, the UM Director develops strategies to achieve departmental and CommonSpirit Health goals and objectives. This position directs the UM staff to meet or exceed operational performance standards. The Director oversees development and implementation of UM policies, procedures and processes; directs and assists with accreditation activities; efficient management of payer requirements, addressing denials effectively, and compliance with payer and regulatory requirements, and reviews and analyzes UM program outcomes and quality metrics. Essential Key Job Responsibilities Manages programs that emphasize appropriate admissions, concurrent and retrospective review of care, and concurrent denials Provides overall direction, design, development, implementation and monitoring of utilization programs to meet the Care Coordination goals and market utilization management goals while maintaining stakeholder satisfaction. Acts as a resource to the medical staff, administrative staff, divisional staff, as well as  external regulatory agencies in all issues relating to utilization management within the Market.   Analyzes and reports significant utilization trends, patterns, and impact to appropriate departmental, Utilization Management, Revenue Cycle, Payer Strategy, and Clinical Joint Operating Committees. Participates in the development and management of department budgets and productivity targets.  Assures compliance with Federal, State, The Joint Commission (TJC), Det Norske Veritas (DNV), and other regulatory agencies and internal standards and requirements Collaborates with Physician Advisory Services to identify denial root causes related to physician performance and facilitates educational training for medical staff on issues related to utilization management. Implements utilization review policies and procedures. Directs recruitment, performance management, coaching, mentoring, training and development. Educates and trains staff on utilization review processes and guidelines. Promotes collaborative practice with revenue cycle stakeholders and facilitates data sharing that provides insight into where best to focus concentrated denial prevention and management efforts designed to reduce costly delays in payment and maximize claims reimbursement revenue. Shall be able to effectively monitor, evaluate and administer the resources of each assigned area, and make substantiated recommendations regarding resource allocation needs for future planning purposes.   Collaborates with division and system leadership, revenue cycle, and other stakeholders to ensure achievement of denial reduction and value capture goals. The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned. Qualifications Required Education and Experience  Required Bachelor's degree in Nursing, Health Care Administration or advanced clinical degree.   Minimum 3 years of clinical case management (Utilization Management, Denial Management, Care Coordination) 5 years of progressively responsible management experience Extensive operational experience in managed care; extensive experience in program planning, implementation, staff development, and needs assessment Comprehensive knowledge of utilization management, financial management that includes revenue cycle, Medicare, Medicaid, and commercial admission and review requirements. Preferred Master's degree in Nursing, Health Care Administration or related clinical field Experience with data analytics to include cost containment, over/under utilization assessment and clinical outcomes Experience with DRG, reimbursement, pricing and coding processes for inpatient and outpatient services Required Licensure and Certifications Current unrestricted RN license where practicing required. National certification of any of the following:  CCM (Certified Case Manager), ACM (Accredited Case Manager) required or within 2 years upon hire. Required Minimum Knowledge, Skills, Abilities and Training Able to apply clinical guidelines to ensure progression of care. Communicate effectively in writing and verbally Must have analytical, critical thinking and problem-solving skills. Collaborate effectively with multiple stakeholders Proficient in the use of computer and multiple software programs.  Ability to actively work within multiple electronic health records (Epic, Cerner, Meditech, and/or Parigon). Understand how utilization management and case management programs integrate. Ability to work as a team player and assist other members of the team where needed. Thrive in a fast paced, self-directed environment. Knowledge of CMS standards and requirements. Proficient in prioritizing work and delegating where indicated. Highly organized with excellent time management skills.

Created: 2024-11-05