Director, Utilization Management

Job Description

Job Description

SUMMARY

The Utilization Management Director leads the utilization review staff and function for KPC HQ. Determines policies and procedures that incorporate best practices and ensure effective utilization reviews. The Director manages and monitors both concurrent reviews to ensure that the patient is getting the right care in a timely and cost-effective way. Provides analysis and reports of significant utilization trends, patterns, and impacts to resources. The UM Director will consult with physicians and other professionals to develop improved utilization of effective and appropriate services.

Duties & Responsibilities

• Develops processes to enhance communication and status to senior management, MDs, and all direct care staff through utilization of current systems and development of new systems to maximize adherence to documentation standards and payments.
• Performs analysis of audit results, denial trends and patterns, appeal letters and recovered payments along with FTE utilization, as a monitoring tool as a basis for employee education and process improvements
• Manages and ensures the productivity of the department in completing concurrent reviews to ensure that the patient is getting the right care in a timely, safe, efficient, and cost-effective way.
• Functions as a liaison between payers and various providers with-in the hospital, such as MDs, Social services, and nursing.
• Prepares monthly departmental statistics.
• Works closely with physicians and other providers including the Physician Advisor to develop improved utilization of effective and appropriate services.
• Participates in the development and management of department budgets and productivity targets.
• Manages human resources utilization, promotes employee satisfaction, supports staff development, and utilizes the progressive discipline process when appropriate.
• Ensures that the UR component of the UM Department are completed as described in the UR Plan.
• Updates the UR Plan to meet CMS requirements for Condition of Participation.
• Receives all denials for care involving patient stays, discusses with UR Physician Advisor, feasibility to appeal. Manages all appeals related to denials of patient stays for all payors/insurance companies.
• Participates in quality improvement processes and assures implementation of regulatory standards.
• Research interdepartmental problems/issues and takes corrective action in timely manner and promotes respectful responsive communication between departments to promote patient centered care.
• Supervises staff in multiple areas. Guides staff in the adherence to applicable standards of care/practice and/or departmental/organizational expectations.

Qualifications

• Bachelor's Degree in Nursing, or related field
• Minimum of two (2) years’ experience in case management, social work, utilization review, and discharge planning in an acute care hospital
• Minimum of two (2) years leadership and department management experience
• Must have working knowledge of Utilization Management and Care Management procedures in an acute care setting
• Must have working knowledge of computer applications such as Excel, Word, and PowerPoint
• Must have the ability to perform cost-benefit and detailed strategic analysis on data and information sets and develop reports accordingly
• Results-oriented professional management with customer service skills including proven time management, organizational, and prioritization skills
• Must possess excellent verbal and written communication skills and thorough knowledge of processes and details integral to utilization review and clinical documentation improvement
• Must have experience in planning and effectively managing departmental budgets and other fiscal responsibilities
• Must be able to demonstrate ability and skill through prior experience and/or academic expertise in actively leading and managing any large-scale change
• Must have expertise in data management and analysis related to length of stay, case mix, resource utilization, etc. with the intent of identifying opportunities for improvement as well as validating current performance
• Must have current knowledge of federal and health plan audit programs such as CMS RAC and other related audit activities, value-based purchasing programs, readmission and other related oversight programs resulting in denied reimbursements.