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Director Utilization Management

1 month ago

Bremerton, United States CommonSpirit Health Full time

Overview Virginia Mason Franciscan Health brings together two award-winning health systems in Washington stateCHI Franciscan and Virginia Mason. As one integrated health system with the most patient access points in western Washington, our team includes 18,000 staff and nearly 5,000 employed physicians and affiliated providers. At Virginia Mason Franciscan Health, you will find the safest and highest quality of care provided by our expert, compassionate medical care team at 11 hospitals and nearly 300 sites throughout the greater Puget Sound region. While you’re busy impacting the healthcare industry, we’ll take care of you with benefits that may include health/dental/vision, FSA, matching retirement plans, paid vacation, adoption assistance,annual bonus eligibility,and more

Responsibilities Job Summary / Purpose 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. Implemen

ts 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.

Qualifications Job Requirements: 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 licensure as a Registered Nurse in the state of Washington National certification of any of the following: CCM (Certified Case Manager), ACM (Accredited Case Manager) required or within 2 years upon hire.

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