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Director of Utilization and Denials Management
1 month ago
We are seeking a highly experienced and skilled Director of Utilization and Denials Management to join our team at WellSpan Health. As a key member of our leadership team, you will be responsible for overseeing the operations of the utilization management department and working closely with hospital, regional, medical group, Population Health, post-acute services, revenue services, and system leadership to achieve strategic goals and improve operations and clinical services.
Key Responsibilities- 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 and 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 the 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.
- Masters Degree Required
- 5 years In leadership experience. Required
- 3 years Utilization Management Experience. Preferred
- Licensed Registered Nurse Preferred
We offer a competitive salary and benefits package, as well as opportunities for professional growth and development. If you are a motivated and experienced professional looking for a new challenge, we encourage you to apply for this exciting opportunity.
