Director, Utilization Management

Description

Position Summary:

The Director of Utilization Management (UM) is responsible for the oversight of the Utilization Management Department for Inpatient and Outpatient Services. This includes the precertification and recertification process, peer to peer reviews, and appeal. The employee will ensure an appropriate discharge plan is in place for each patient discharge. The employee will accurately report the authorization status of patients, denials and appeals status to the CEO, CFO, and Business Office staff. The Director will ensure all UM staff follow department and facility procedures and ensure effective communication with all relevant departments regarding patient care needs.

Position Responsibilities:

Clinical / Technical Skills (40% of performance review)

• Oversees the request for services including the determination of appropriate level of care, initial authorization, the concurrent review process and appropriate discharge planning.
• Reviews the quality of documentation for each level of care to ensure clinical effectiveness and appropriateness of treatment.
• Participates in clinical team review and evaluation of services offered at the facility to ensure goals and objectives are consistent throughout programs and facility expectations.
• Meets regularly with program managers, physicians, clinical staff and the Medical Director to ensure compliance with program goals and objectives.
• Works alongside the Chief Nursing Officer, the Director of Clinical Services and other leadership in the development of the treatment team agenda while educating the team member of the UM role for same.
• Maintains an active involvement and awareness of all patient admissions, discharges and transfers to alternate levels of care. Oversees continuity of care for each level of care transition.
• Oversees the coordination with managed care companies or other third-party payors regarding peer reviews, retrospective reviews and appeals. Documents and updates the denial log to reflect same.
• Maintains logs of all certifications and denials along with updated status of same.
• Develops and maintains processes to minimize denials and communication of same to the CFO and Business Office Manager.
• Reviews benefit verifications and updates for level of care benefits with the Business Office to ensure and optimize maximum patient care and treatment.
• Ensures processes are followed to provide adequate continuity of care and communication to families/support systems as well as referral sources for treatment and aftercare planning.
• Reports results of daily treatment team meetings all discharges and status of high-risk cases such as limited benefits, peer reviews, denials or unplanned discharges.
• Provides education to other UM/other departments/leadership on documentation requirements and criteria to assist with ensuring accurate information and follow through for treatment planning and insurance reviews.
• Strong working knowledge of external review organizations (ie: Medicare/Managed Care/Medicaid) with knowledge of payor resources and planning.
• Ability to state local laws, ordinances, and practices governing involuntary hospitalization and ensure compliance with same.
• Ensures that hiring, disciplinary actions and termination procedures are in accordance with hospital policies.
• Ensures adequate orientation for new employees of the UM Department while providing ongoing educational needs and professional development of staff.
• Facilitates UM team meetings no less than quarterly, or as set by the CEO, with a set agenda for education and training.
• As necessary, participates in Administrator on Call rotation.
• Demonstrates an ability to be flexible, organized and function well in stressful situations.
• Interacts professionally with patient/family and provides explanations and verbal reassurance as necessary.
• Maintains a good working relationship/team work both within the department and with other departments.
• Ensures that documentation meets current standards and policies.
• Manages and operates equipment safely and correctly.
• Supports and maintains a culture of safety and quality.
• Demonstrates understanding of HIPAA.
• Demonstrates understanding of Patient Rights and Patients Right to Report and Patient Advocacy

• Perform other duties as assigned.

Safety (15% of performance review)

• Strives to create a safe, healing environment for patients and family members
• Follows all safety rules while on the job.
• Reports near misses, as well as errors and accidents promptly.
• Corrects minor safety hazards.
• Communicates with peers and management regarding any hazards identified in the workplace.
• Attends all required safety programs and understands responsibilities related to general, department, and job specific safety.
• Participates in quality projects, as assigned, and supports quality initiatives.
• Supports and maintains a culture of safety and quality.

Teamwork (15% of performance review)

• Works well with others in a spirit of teamwork and cooperation.
• Responds willingly to colleagues and serves as an active part of the hospital team.
• Builds collaborative relationships with patients, families, staff, and physicians.
• The ability to retrieve, communicate, and present data and information both verbally and in writing as required
• Demonstrates listening skills and the ability to express or exchange ideas by means of the spoken and written word.
• Demonstrates adequate skills in all forms of communication.
• Adheres to the Standards of Behavior

Integrity (15% of performance review)

• Strives to always do the right thing for the patient, coworkers, and the hospital
• Adheres to established standards, policies, procedures, protocols, and laws.
• Applies the Mission and Values of SUN Behavioral Health to personal practice and commits to service excellence.
• Supports and demonstrates fiscal responsibility through supply usage, ordering of supplies, and conservation of facility resources.
• Completes required trainings within defined time periods.
• Exemplifies professionalism through good attendance and positive attitude, at all times.
• Maintains confidentiality of patient and staff information, following HIPAA and other privacy laws.
• Ensures proper documentation in all position activities, following federal and state guidelines.

Compassion (15% of performance review)

• Demonstrates accountability for ensuring the highest quality patient care for patients.
• Willingness to be accepting of those in need, and to extend a helping hand
• Desire to go above and beyond for others
• Understanding and accepting of cultural diversity and differences

Qualifications

Education

• Required: Bachelors degree in Nursing, Social Work, Mental Health/Behavioral Sciences, or related field.
• Preferred: Masters degree in Nursing or Behavioral Health
• Maintains education and development appropriate for position.

Experience

• Required: A minimum of five (5) years direct clinical experience in a psychiatric or mental health treatment setting. Experience in patient assessment, family motivation, treatment planning, and communication with external review organizations or comparable entity.
• Preferred: One (1) year of experience in managing a related function. Current license in state of employment as LVN/LPN, RN, LMSW, LPC, or applicable license