Corporate Dir of Utilization Management

Florence, SC

TRACKING CODE

7018

JOB DESCRIPTION

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

WORK SCHEDULE

Full time

JOB LOCATION

Florence, SC, United States

POSITION TYPE

Full time