Director of Utilization Management and Denials

4 weeks ago


York, Pennsylvania, United States WellSpan Health Full time

Job Summary

WellSpan Health is seeking a highly skilled Director of Utilization Management and Denials to oversee the operations of the utilization management department. The ideal candidate will have a strong background in leadership and experience in utilization management.

Key Responsibilities

  • Supervise and oversee the utilization management process for preauthorization, concurrent review, denials, and appeals for System acute care facilities.
  • Direct, coordinate, and evaluate the efficiency and productivity of utilization management functions.
  • Lead strategic goals and priorities across utilization management that support WellSpan's strategic priorities and objectives.
  • Develop, review, implement, and oversee effective administration of Utilization Management workflow and processes in accordance with contract compliance as well as regulatory requirements.
  • Oversee and evaluate the activities and effectiveness of Utilization Management activities.
  • Build a high-functioning team that meets all operating goals, including quality, efficacy, administrative expense, customer service, performance improvement, regulatory requirement satisfaction, and staff engagement.
  • Provide oversight of utilization management, denials, and Prior Authorization activities to ensure utilization review activities are conducted timely in accordance with internal policy and payor requirements.
  • Monitor operations and implement strategies that promote compliance with regulatory standards.
  • Provide mentoring and coaching to direct reports to build and strengthen Utilization Management effectiveness.
  • Ensure regular departmental staff meetings are conducted and action items and follow-up issues are completed.
  • Partner with other Departments to develop, implement, and monitor system-wide performance improvement initiatives for Utilization Management measures.
  • Coordinate with other operational departments to identify and achieve workflow improvements to gain process and procedure efficiencies and create standardized reporting across all functional areas.
  • Identify, design, and implement Process Improvement opportunities that support utilization management operations.
  • Participate as a member of Utilization Management Review Committees. Co-chair's System Utilization Management Committee.
  • Work closely with Medical Director to identify trends in payor denials and appeals.
  • Serve as point of contact for System acute care utilization review issues and resolutions with payers. Collaborate with Payer Contracting regarding payer issues. Attend Joint Operations Committee Meetings with payers.
  • Organize and assist Medical Director with System Utilization Management Committee (URC) meetings. Prepare reports for review at the URC meeting.
  • Work with medical and professional staff on a case-by-case basis to obtain appropriate clinical documentation for review as well as coding activities and DRG assignments.

Requirements

  • Masters Degree Required
  • 5 years In leadership experience. Required
  • 3 years Utilization Management Experience. Preferred
  • Licensed Registered Nurse Preferred

What We Offer

WellSpan Health is an Equal Opportunity Employer. We are committed to treating all applicants fairly and equitably, regardless of their job classification. If you require assistance or accommodation due to a disability, please reach out to us via email. We will evaluate requests for accommodation on a case-by-case basis.



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