Director Utilization Management Job in New York, New York Us
We have been retained by a vibrant, fiscally sound, teaching hospital, which provides a full spectrum of care to the community it serves, to locate a Director of Utilization Management. This person will report to the Chief Medical Informatics Officer.
Our client seeks a candidate with a Bachelor’s in Nursing plus a Master’s in Nursing, Healthcare Administration, Business or a related field. He/she must have a solid clinical background coupled with a minimum of five years of progressive leadership experience in Utilization/Case Management, Quality Improvement, Managed Care, or Risk Management. This person must have extensive knowledge of HCFA/IPRO, OHSM, HANY and TJC as they relate to Utilization Management/Quality Improvement. Additionally he/she should have knowledge of InterQual Medical Necessity Criteria, Milliman Robertson Clinical Guidelines, DOH and CMS regulations. Highly developed communication skills, both written and verbal, are a necessity.
Responsibilities include:
§ Coordinate and administer all operations of the Utilization Management Department, while supporting policies and goals of the hospital
§ Work closely with physicians and nursing staff to reduce denials while dealing with an aggressive insurance industry
§ Review, analyze and present data related to Concurrent and Retrospective Review Activity, Performance Improvement, Length of Stay, Case Mix Index and utilization of hospital resources specific to service, practitioner and payor in order to identify and report patterns and trends
§ Monitor denial management activities to identify patterns and respond appropriately in order to maximize reimbursement
§ Insure appeals are submitted in a timely manner; monitor final determination responses to track outcomes of appeals process; meet with physicians and department heads to review and address denial patterns; report to hospital administration on denial activity, appeal results and final determination outcomes
§ Implement denial prevention efforts with Concurrent Review staff
§ Work in conjunction with Patient Financial Services, Health Information Management, Performance Improvement and Risk Management to balance cost, quality and risk in the provision of patient care
§ Maintain policies and procedures, workflows, reports and statistics for distribution to chiefs of service, department heads and administration
§ Maintain and monitor department budget
§ Insure a collaborative approach to discharge planning with Social Work for placement of patients in the most timely and efficient way as per CMS standards.
§ Adhere to established policies relating to safety and security, risk management, and infection control
§ Coordinate the implementation of new processes as they relate to Utilization Management, Continuum of Care, Discharge Planning and Denial Management policies
§ Participate in various hospital committees
Our client offers a very competitive salary and excellent benefits package.
The employer is responsible for all fees, and all inquiries are held in strict confidence.
If you or someone who you know might be interested in further information about this position, please contact Marilyn Weintraub, Recruitment Manager mweintraub@ppasearch.com or 914-251-1000 x112.