Develop a strategic vision and plan for Utilization Review. Develop performance metrics and analyze data to enhance department services and reassess the strategic direction of the departments. Oversee the management and operations of the department, including minimization of denials of patient admissions and continued stays, identification of over and under utilization of resources through medical record review of patient stays and training. Serves as an educational and communications resource to Administration, Department heads, physicians, and other necessary groups regarding Utilization Review.
·Utilization Management - Appeals
Communicate with the Medicaid or Medicare Peer Review Organization as regulations require and concerns arise, including the review of and the challenge of adverse findings with appeals when appropriate. Directs department in the communication with Third Party Payers to certify inpatient stays and challenge adverse determinations when appropriate. This also includes the responsibility for coordinating and communicating responses to potential quality concerns from external payors. Involves respective departments and Medical Staff divisions for input. Manages the team coordination of chart reviews for the denial appeal process. Cases denied for medical necessity, benefit exclusion, prior authorization clarification/appeals are reviewed by UR nurse specialists in the UR department. Further information is collected (could be from ancillary departments, medical staff, outpatient information etc.) synthesized and drafted into a response. Medical staff is engaged at varying levels (conversations, clinical papers, appeal letter) and information is incorporated into the appeal letter. Process is followed until all appeal options are exhausted.
·Utilization Management - Other
Responsible for Utilization Review in meeting current JCAHO, Medicaid, Medicare, and other third party payer standards and requirements, while keeping abreast of all changes. Work collaboratively with billing areas to ensure that processes for data collection and clinical review information maximize reimbursement. Collaborate with Admitting Department to provide information regarding payor requirements, changes in process and updates on activities. The focus is to work in collaboration with Access Services leadership to facilitate (ensure) effective registration, insurance verification, and notification to optimize work flows. Work closely with the Epic ADT and clinical documentation teams regarding key information needed in the system for compliance and as a review agent for issues such as order set clarification.
·Revenue Cycle Support
Analyzes and interprets Utilization Management language in third-party payer contracts and makes recommendations as requested by senior management. Develop and maintain close working relationship with the Revenue Cycle Management team with focused activity to Hospital Billing and Professional Billing. Includes participation in payor operations meetings/Joint Operating Committees (JOC) to articulate concerns, seek clarification, pursue further activities to resolve issues. Is primary liaison to Medical Management leadership at the payor level. When necessary, work with any on-site review persons from third party payers to assure they perform reviews in accordance with the Memorandum of Understanding which is part of their contract, including the review of the MOU for each company with the contract specialists prior to signing of the agreements. Maintain open communication with these individuals for the good of patient care.
Attend discharge planning meetings as appropriate in the discharge planning process. Communicate and advise physicians, social service, nursing, and other patient care givers in financial and utilization information to assist in the coordination of timely and appropriate patient discharges. Is a resource to other departments for elements of utilization and authorization (e.g. Radiology, Outpatient Pharmacy.) Assists in distribution to/education of departments on changes related to pedetermination, pre/prior authorization, appeals process for payors etc.
Works closely with the chairperson of the Utilization Review (UR) Committee to develop the UR Plan, Committee performance measures, communication/education plan and responses to changes in the payor foci UR department staff in conjunction with the Director assist divisions in developing educational programs (e.g. observation vs. inpatient status), assist with patient status review and inclusion of same in order sets, enlist/educate physicians in the peer-to-peer review process and denial/appeals activity.
Develop, evaluate and manage annual fiscal operating and capital equipment budgets for the Utilization Review department. Evaluate and manage operating revenue/expense variances monthly and communicate to Assistant Vice President, Revenue Cycle Management. Develop methods for fiscal analysis, conduct financial and quantitative analysis and monitor existing or proposed programs and services. Coordinate and approve purchasing requisitions, leases, vendor contracts and service contracts.
Ensure that a sufficient number of qualified and competent persons are available to accomplish the goals, strategies and tactics of the department. Manage the selection, development, motivation, appraisal and discipline of reporting personnel. Provide supervision of assigned staff for carrying out department goals and objectives and the Medical Center mission and values. Prepare and present annual performance evaluations. Make job requirements and goals for each position clear to employees and provide sufficient training to achieve the desired level of competency; document evidence of competence on an annual basis. Ensure that orientation and in-service training and continuing education are provided to achieve the desired level of performance. Maintain accurate records of time worked by staff and ensure appropriate coverage as required by the department. Develop first line supervisors to effectively manage staff to oversee the day-to-day operations.
Ability to work independently to develop, implement and manage projects; knowledge of the principles and concepts of project management including proficiency with relevant project management tools
Recognizing when sufficient information has been obtained to make a decision; evaluating available alternatives and using sound thought processes and relevant experience to make the optimal choice in a timely manner; making difficult decisions even in highly ambiguous situations
Working cooperatively with others to achieve group goals; proactively adjusting one's style and efforts to complement those of others on the team; being pleasant, agreeable, and easy to work with; valuing group success as much or more than individual success
Understanding and showing respect and appreciation for the uniqueness of all individuals; leveraging differences in others' perspectives and ideas; appreciating cultural differences and adjusting one's approach to successfully integrate with others who are different from oneself
Knowledge of related regulatory requirements and standards
Demonstrated leadership and management skills
Formulating credible, effective, long-range strategies to attain overarching organizational objectives; anticipating future trends, as well as potential threats or opportunities; accurately predicting how strategies will play out
Proficiency in basic computer applications such as Microsoft Office (PowerPoint, Word, Excel), e-mail, and internet
Strong organizational and project management skills to handle projects independently.
Demonstrates an independent work initiative, sound judgment, diplomacy, tact and professional demeanor
Prioritization and time-management skills sufficient to meet deadlines in a fast-paced environment
·Analysis - Basic
Analytical ability sufficient to evaluate data, make judgments and recommendations
Ability to independently work through details of a problem to reach a positive solution
·Communication - Advanced
Excellent verbal, written and interpersonal communication skills.