Utilization Management Director

Newport News, Virginia Overview Responsible for Inpatient Utilization Management function for Riverside Health System's Acute Care Hospitals. Responsible for overall policy and operational accountability for utilization review to meet system strategic goals and directions. Oversees team members with responsibility for all utilization review activities including monitoring all admissions, concurrent, retrospective and denial reviews, and communicating the patient's plan of care to insurance companies. Partners with Physician Advisor staff as indicated and is responsible for all UM Committee Meetings. Maintains accuracy to track all claims, runs productivity reports, and ensures the timely entry of information related to coordination of reviews in all appropriate systems. Develops and revises policies and procedures, monitors performance, coaches and counsels staff. Participates in process improvement, survey preparedness, insurer collaboration and system/hospital committees. What you will do Provides direct oversight to UM Nurse Care Management team members. Monitors adherence to policies and procedures, evaluates critical thinking and complex decision making skills. Collaborates with Inpatient Care Management Leadership teams, and revenue cycle team members. Responsible for the annual budget process to include appropriate resource allocations for FTE’s, skill mix, replacement, succession planning, capital expenditures, and expenses. Completes variance review, analysis and action plans for budget objectives. Ensures that annual competencies are completed. Schedules staff for maximum effectiveness to achieve system and facility goals. Ensures department remains current with regulatory changes that impact UM. Provides oversight of UM RN's and appeal nurses who manage all concurrent and retrospective denials. Collaborates with the physicians/physician advisors to ensure compliance with issues relevant to non-covered/possible denials. Obtains appeal information from payer, including peer-to-peer information, provides the information to the attending physician, the patient, and the Care Management Leadership, and documents appeal information in Electronic Health Record Certification Entry Screen. Documents outcomes and steps for next level of appeal. Maintains knowledge and provide staff trainings to share the understanding of Medicare/Medicaid regulatory requirements and conditions of participation. Maintains knowledge and understanding of Managed Care and other Payer requirements for appropriate level of care and necessity of continued stay. Defines department scope and practice utilizing guiding principles from ACMA Hospital Case management. Qualifications Education Masters Degree, Nursing, Business, Healthcare Administration or related field (Required) Experience 5-6 years Case Management or Utilization Review in acute care setting (Required) 3-4 years Supervisory experience (Required) Licenses and Certifications Registered Nurse (RN) - Virginia Department of Health Professions (VDHP) Upon Hire(Required) Accredited Case Manager (ACM) - American Case Management Association (ACMA) within 1 Year(Required) or Certified Case Manager (CCM) - Commission for Case Manager Certification within 1 Year(Required) To learn more about being a team member with Riverside Health System visit us at https://www.riversideonline.com/careers. If loving your work is important to you, consider a career at Riverside. By joining our team, you can make a difference in people's lives. Our mission is to care for others as we would care for those we love. We extend that sense of caring to every patient, resident and customer, as well as to each member of our team. We offer care at all stages of life, in hundreds of locations, giving you room to grow your career, along with great benefits and perks. At Riverside Health, your trust and safety are our top priorities. Unfortunately, job scams are on the rise across the country, and we want to help you feel confident in knowing what is — and is not — part of our hiring process. Learn more about how to recognize a legitimate Riverside job opportunity and what to do if you suspect a scam by visiting this site.