PeaceHealth is seeking a Manager Utilization Review (Remote) for a Full Time, 1.00 FTE, Day position. The general salary range for this job opening at PeaceHealth is $52.23 – $78.35. The actual hiring rate is dependent upon several factors, including but not limited to, the job/position responsibilities, location, terms of the applicable collective bargaining agreement, education, training, work experience, seniority, work performance, etc.
Coordinates the design, development, implementation, and monitoring of the enterprise utilization review functions. Oversees daily operations, which include leading staff performing utilization management/clinical denial activities. Responsible for the management of vendor contract performing utilization review functions. Functions as the internal expert related to the appropriate resource utilization, coordination of payer communication and utilization review and management. Matrixed reporting relationship with Revenue Integrity to facilitate integration of denials management processes and team members. Responsible for carrying out duties in a manner to ensure success in financial management, human resources management, leadership, quality, and operational management objectives. Participates in program development and UR Department performance improvement. Responsible for day-to-day operations of the department, assists with the budgeting process, and professional development.
**Must live in Oregon, Washington, Texas or Alaska.**
- Participates in the development and management of department budgets and productivity targets.
- Serves as point of contact for all contract-specific utilization review activities and develops action plans to address identified opportunities.
- Manages team of program managers in a hybrid/remote model, promotes employee satisfaction, supports staff development, and utilizes the progressive discipline process when appropriate.
- Collaborates with local Acute Care management directors, program coordinator and Revenue Cycle to develop standard work and expectations for the utilization review process, including timely medical necessity screening to ensure patients are placed at the appropriate patient status.
- Collaborates with nursing, physicians, admissions, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status.
- Ensures processes are in place for proactive reviews of surgical and other procedures to confirm accurate perioperative pre-authorization and patient class order reconciliation process. Assesses compliance to regulatory and health plan requirements for authorization, including Medicare Inpatient Only List and communicates to provider to obtain accurate order prior to procedure and post procedure.
- Ensures UR clinical specialists identify, documents and communicate avoidable days and delays in services that may prolong length of stay and analyze data to monitor trends for opportunities to improve services. Partners with local hospital Director Care Management to report avoidable days, trends, and actions to UR Committees, as appropriate.
- Partners with physician advisor (UM/CDI Medical Director) to engage in second level review and working with attending physicians to document completely to ensure patient class determinations.
- Serves as expert resource for all Medicare Notification Letters and ensures appropriate distribution of all letters (IMM, MOON, HINN, etc.) including full documentation to meet regulatory requirements to ensure correct billing.
- Collaborates with Contracting and is an active participant in Joint Operating Committees.
- Develops and implements process to manage and respond to all concurrent and post-discharge third party payer denials of outpatient and inpatient cases alleged to be medically inappropriate. Including, but not limited to; Peer-to-Peer as appropriate, written appeal letters when indicated, documentation of interventions and outcomes and monitor to identify opportunities to improve processes for denial prevention.
- Serves as the internal expert for Care Management staff and others on documentation and reimbursement requirements. Serves as a resource to the health care team for utilization and denial management. Liaises with provider office staff and facilitates meetings with payers, as appropriate.
- May participate in the Utilization Review Committee to present medical necessity data and outcomes and partners with care management leadership to develop action plans for improvement.
- Performs other duties as assigned.
What you bring:
- Graduate of an Accredited School of Nursing.
- Bachelor's Degree in Nursing or related field required.
- Master's Degree Preferred.
- Minimum of 5 years' experience in an acute care hospital required.
- Minimum of 2 years management experience required.
- Experience in utilization management required.
- Third-party reimbursement knowledge required.
- Experience in surgery, emergency and/or critical care preferred.
- Strong statistical, data analysis, and clinical application experience preferred.
- Experience in process/quality improvement, quality measurement, data abstraction, data analysis and reporting, and data integrity preferred.
- Current Registered Nurse licensure upon hire and preferred licensure in Washington and Oregon within one year of hire.
- National certification of any of the following: CPHM (Certified Professional in Healthcare Management), CCM (Certified Case Manager), ACM (Accredited Case Manager) required or completed within one year of hire.
- Ability to deliver financial results for areas of accountability.
- Knowledge of or ability to learn financial management related to UR function and reporting, quality improvement processes, and human resources management.
- Able to effectively monitor, evaluate and administer the resources of each assigned area, and make substantiated recommendations regarding resource allocation needs for future planning purposes.
- Able to communicate effectively in writing and verbally, ability to interact with a wide variety of individuals, and handle complex and confidential situations. (Required)
- Ability to lead, delegate, analyze information and problem solve.
- Strong skills in confidentiality, integrity, creativity, and initiative.
- Able to supervise staff in a remote work environment across all three networks including larger acute and critical access hospitals.
Department / Location Specific Notes
- Consistently operates computer and other office equipment.
- Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects.
- Predominantly operates in an office environment.
- Some time spent on site in medical/hospital setting.
- Ability to communicate and exchange accurate information.
- The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading.
PeaceHealth is committed to the overall wellbeing of our caregivers: physical, emotional, financial, social, and spiritual. We offer caregivers a competitive and comprehensive total rewards package. Some of the many benefits included in this package are full medical/dental/vision coverage; 403b retirement plan employer base and matching contributions; paid time off; employer-paid life and disability insurance with additional buyup coverage options; tuition and continuing education reimbursement; wellness benefits, and expanded EAP and mental health program.
See how PeaceHealth is committed to Inclusivity, Respect for Diversity and Cultural Humility.
For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state or federal laws.
PeaceHealth requires a completed Primary Vaccine Series (e.g., 2 dose monovalent Pfizer, Moderna or Novavax series or 1 dose J&J vaccine series) or be Up to Date (receiving the most recent Pfizer/Moderna bivalent vaccine/booster) for COVID-19 vaccination prior to their start date. PeaceHealth has a medical and religious exemption request process for those that are unable to receive the COVID-19 primary vaccine series due to medical/religious reasons. For caregivers that will be working in Oregon there is a personal vaccine exemption form that may be requested.