Director Enterprise Utilization Review

Job Description:

Director Enterprise Utilization Review

time type

Full time

posted on

Posted Yesterday

job requisition id

JR25-09469

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Responsible for the direction of the utilization review functions of the health system in regards to patient status and level of care. Works in collaboration with key stakeholders and clinical leaders to ensure compliance, efficiency, and improvement. Provide system opportunities that will drive operational improvement, compliance, consistency, and collaboration.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s Degree in Finance, Business Administration, or Nursing.

EXPERIENCE:

1. Five (5) years of healthcare management experience in utilization, finance, or case management.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Master’s Degree in Business Administration or Public Health.

CORE DUTIES AND RESPONSIBILITIES:

1. Acting Director of Utilization Review for assigned hospitals.  Functions include inpatient concurrent medical necessity management and post discharge denials management, including reporting and process improvement initiatives.

2. System oversight in relation to Utilization Review functions and processes.  Providing guidance to the system directors of case management and implementing processes.  Coordinate a monthly collaboration/affinity call reporting key data and ensuring processes are consistent.  Identify site system improvements in relation to Utilization Review.

3. Administrative chair of assigned hospital Utilization Review committee that support the chair and Medical Director of the department.  Ensure the Utilization Review policy is effectively implemented including meeting requirements and process initiatives. 

4. Oversees the division that has direct interaction with clinical leaders to ensure compliance of utilization review metrics and indicators.

5. Provides communication and analysis to senior leadership and other key stakeholders in relation to initiatives and improvements.  Provides guidance and opportunities to bring consistency to the health system.

6. Oversees key statistics to make process improvements within health system.  Ensure appropriate communication is provided to Finance Leadership, Clinical Leadership, and Compliance Leadership within the health system.

7. Works with all Case Management Directors with local issues related to medical necessity and process improvements.  Provide guidance and oversight of their Utilization Review functions.

8. System administrative advocate in relation to utilization review and escalation with insurance carriers.  Providing consistency and ensuring efficient and credible work functions.

9. Key IT contact for EPIC changes or implementation in relation to Utilization Review functions.

10. Ensures coordination and work functions and processes from the physician advisor group.  Collaborates on processes with the Medical Director of Utilization Management to develop best practices.  Work with external physician advisor group as directed by Medical Director.

11. Manages assigned cost center and all financial aspects of the cost center to include accounts payable, budgeting, and variances.

PHYSICAL REQUIREMENTS:

1. Ability to sit for prolonged periods of time, manual dexterity.

WORKING ENVIRONMENT:

1. Office environment.

2. Clinical setting.

SKILLS AND ABILITIES:

1. Skill in organizational matters, including time management, prioritization, multitasking, and problem-solving.

2. Ability to establish and maintain effective working relationships with patients, physicians and other clinical staff, and the public.

3. Ability to use excellent customer service, written and oral communication skills.

4. Superior knowledge of computer programs such as word processing, spreadsheet and email applications.

5. Knowledge of ICD-10 Codes and CPT coding, insurance authorization with Third Party Payers, payment provisions and regulations, revenue cycle operations, third party reimbursement regulations and medical terminology.

6. Knowledge of all aspects of payer relations, claims adjudication, contractual claims processing and general reimbursement procedures. 

7. Knowledge of clinic policies and procedures.

8. Knowledge of reimbursement impact statistics such as; CMI, CC%, LCD, NCD, LOS, and Utilization Review.

9. High-level analytical abilities and understanding of key health care metrics that give the ability to understand all the clinical workflows within the organization to make change and improvements.

10. Demonstrates a high level of initiative and performs as a self-starter in daily activities.

Additional Job Description:

Scheduled Weekly Hours: 40

Shift:

Exempt/Non-Exempt: United States of America (Exempt)

Company: SYSTEM West Virginia University Health System

Cost Center: 553 SYSTEM Utilization Review