Market Director Utilization Management Lead

1 month ago

Lexington, Kentucky, United States Catholic Health Initiatives Full time
Job Summary

Catholic Health Initiatives seeks a highly skilled and experienced Market Director of Utilization Management to lead the development, implementation, and evaluation of the Utilization Management Program in support of the CommonSpirit Health Care Coordination model.

Key Responsibilities
  • Develop and implement strategies to achieve departmental and CommonSpirit Health goals and objectives.
  • Direct the Utilization Management staff to meet or exceed operational performance standards.
  • Oversee the development and implementation of UM policies, procedures, and processes.
  • Collaborate with the Division Director Care Coordination to develop strategies to achieve departmental and CommonSpirit Health goals and objectives.
  • Act as a resource to the medical staff, administrative staff, divisional staff, and external regulatory agencies in all issues relating to utilization management within the Market.
  • Analyze and report significant utilization trends, patterns, and impact to appropriate departmental, Utilization Management, Revenue Cycle, Payer Strategy, and Clinical Joint Operating Committees.
  • Participate in the development and management of department budgets and productivity targets.
  • Assure compliance with Federal, State, The Joint Commission (TJC), Det Norske Veritas (DNV), and other regulatory agencies and internal standards and requirements.
  • Collaborate with Physician Advisory Services to identify denial root causes related to physician performance and facilitate educational training for medical staff on issues related to utilization management.
  • Implement utilization review policies and procedures.
  • Direct recruitment, performance management, coaching, mentoring, training, and development.
  • Educate and train staff on utilization review processes and guidelines.
  • Promote collaborative practice with revenue cycle stakeholders and facilitate 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.
  • Collaborate with division and system leadership, revenue cycle, and other stakeholders to ensure achievement of denial reduction and value capture goals.
Qualifications
  • Required Education and Experience:
    • 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.

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