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Corporate Dir of Utilization Management

Florence, SC



Corporate Director of Utilization Management

Essential Functions •    Maintains a professional image and exhibits excellent customer relations to patients, visitors, physicians, and co-workers in accordance with our Service Excellence Standards and Core Values.  •    Shall demonstrate leadership and commitment with respect to the quality management system by: •    promoting the use of the process approach and risk-based thinking; •    engaging, directing and supporting persons to contribute to the effectiveness of the quality management system requirements; •    promoting improvement. •    Translates the McLeod Health vision and goals into practical strategies.  •    Responsible for operational management of the Utilization Management Department •    Provides oversight of the utilization management process by ensuring an organization-wide, multidisciplinary approach to balancing cost, quality, and service in the provision of patient care.   •    Develops and implements standard work including regulatory requirements and operational policies and procedures for utilization management services. •    Works with others members of leadership team to identify and implement elements of a comprehensive utilization management plan necessary to satisfy Medicare Conditions of Participation, Medicaid Program requirements, and utilization management requirements for all payers.  •    Responsible for concurrent prior authorization process and concurrent denials/appeals process.  •    Responsible for inpatient notification process/team.  •    Provides managerial oversight to external and internal secondary review processes.  •    Responsible for review of services to ensure they are medically necessary, provided in the most appropriate care setting, and at or above quality standards.  •    Works to ensure McLeod Health UM Plan activities and outcomes are systematically monitored, measured, assessed and improved throughout the organization.  •     Acts as a liaison between clinical and non-clinical areas to support utilization review, clinical documentation improvement, and claim denials management. •    Responsible for identification and resolution to problems that may cause or result in excessive resource utilization and inefficient delivery of care. •    Utilizes and interprets data to identify factors allowing for rapid change/course adjustment to stay on target and achieve operational and program goals. •    Works closely with the Physician Advisor and denials team to develop and implement effective utilization management strategies which prevent denials and increase the number of successful requests for appeals. •    Helps to facilitate Corporate Utilization Management Committee meetings.  •    Responsible for facilitating appropriate lengths of stay and reimbursement for all hospital admissions in accordance with its goals and objectives.  •    Assists in the planning and development of an annual budget; analyzing variances; initiating corrective actions. •    Engages in matrix leadership across McLeod Health entities

Work Schedule: 80 Hours Biweekly. Full Time

Qualifications/Training: •    3-5 or more years of acute care hospital experience •    3-5 years of Case Management/Utilization Management experience  •    1-2 years data entry/computer experience 

Licenses/Certifications/Registrations/Education: •    Registered Nurse from an NLN accredited school of nursing required •    Licensed RN to practice within the applicable region of employment and coverage area of responsibility is required


Full time


Florence, SC, United States


Full time

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