Director Utilization Management

Location: Larkin Bldg @ Exchange Street

Location of Job : US:NY:Buffalo

Work Type : Full-Time

Shift 1

Job Description

Work flows across all sites. This includes consistent practice and issuance of admission denials, concurrent denial notices, level of care determinations, ensuring patients are afforded appeal rights and financial responsibility is appropriately assigned. Responsible for timely concurrent and retrospective medical necessity appeals and denial management for all lines of business including quarterly insurance company audits, CMS RAC /MAC determinations. Responsible for review of data, determining trends, making recommendations to Senior Financial Team, implementing changes to meet demands. Works closely with Compliance to meet CMS, DOH & DNV regulations. Responsible for system wide implementation of Payer contracts as related to Utilization Review. Has significant quality of care and financial implications to Kaleida. Key contact for Utilization review issues / concerns / and implementation of consistent polices with the commercial insurance companies. Works closely with contracting for recommendations on improving utilization position within contracts. Responsible for review of data, determining trends, making recommendations to Senior Financial Team, implementing changes to meet demands.

Education And Credentials

Bachelor's in Nursing, Healthcare, Healthcare Admin or similar required. Master's in Nursing, Healthcare, Healthcare Admin or similar preferred.

Experience

10 years of experience in a healthcare environment required. 5 years of experience in utilization management, discharge planning. 5 years' work experience in Payer / Insurance HMO environment. Knowledgeable in CMS, DOH regulations. Experience with regulatory audits. 5 years of experience with nsurance Carriers, payer policy trends & Revenue Cycle management concepts. 3 years of experience with Interqual Software, Excel, Microsoft. 3 years of experience in a multi-hospital system required. 3 years of experience with Federal, State and accreditation guidelines, financial principles, coverage issues and insurance / managed care practices. RN license required upon hire.

Working Conditions

Essential

• Weight Requirement - Sedentary (10 lbs)
  
  

Job Details

Department : BGMC Utilization Review

Standard Hours Bi-Weekly : 75.00

Weekend/Holiday Requirement: No

On Call Required : No

With Rotation

Scheduled Work Hours: 8a-4p

Work Arrangement : Onsite

Union Code : N00 - Non Union KH

Requisition ID# : 17678

Grade : EX218

Pay Frequency : Bi-Weekly

Salary Range: $ 109,414.50 - $150,442.50

• Wage will be determined based on factors such as candidate's experience, qualifications, internal equity, and any applicable collective bargaining agreement.
  
  

Kaleida Health’s mission is to advance the health of our community, and we believe our diversity, equity, and inclusion (DEI) strategic work is mission- critical for the good of our workforce and the community who need and depend on our care and services. We understand that racism and health inequities stand firmly in the way of advancing the health of our community, and Kaleida Health envisions DEI as the pursuit of equity and restorative justice for every person. We will exemplify courage and accountability through both the professing and practice of our core values for our friends, colleagues, and community. Kaleida Health is committed to creating a culture of equity and inclusion where diversity is valued and celebrated!