PeaceHealth is seeking a Dir Utilization Review for a Full Time, 1.00 FTE, Day position.
Must reside in Oregon, Washington, or Alaska.
Must be fully vaccinated for COVID-19 including 2 doses of a 2-dose series or 1 dose of a 1-dose series plus 14 days beyond the final dose prior to start date.
Directs the design, development, implementation, and monitoring of the enterprise utilization review functions. Oversees daily operations, which include supervising the staff performing case management and utilization management activities. The goal is to achieve clinical, financial, and utilization goals through effective management, communication and role modeling. Functions as the internal resource on issues related to the appropriate utilization of resources, coordination of payer communication and utilization review and management. Responsible for carrying out duties in a manner to assure 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, assists with personnel recruitment, retention, corrective action and professional development.
- Participates in the development and management of department budgets and productivity targets.
- Directs team of UR Clinical Specialists in a remote model, promotes employee satisfaction, supports staff development and utilizes the progressive discipline process when appropriate.
- Collaborates with system director and professional development specialist 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 and level of care, professional communication with physicians and nurses and other members of the care team.
- Collaborates with nursing, physicians, admissions, fiscal, 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 and ensure correct billing.
- Works collaboratively with Inpatient Care Management, Patient Accounting, Patient Admission and Registration, HIM, and the Finance Department to analyze one-day Medicare inpatient stays and identify opportunities to improve.
- 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.
QUALIFICATIONS Required unless otherwise stated
- Graduate of an accredited school of nursing.
- Bachelors’ degree in nursing or related field required.
- Masters’ degree preferred.
- Minimum of seven years’ experience in an acute care hospital required.
- Minimum of five 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 hiring.
- 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.
- Ability to lead, delegate, analyze information and problem solve.
- Demonstrates evidence of strong skills in confidentiality, integrity, creativity, and initiative.
- Must be able to supervise staff in a remote work environment across all three networks including larger acute and critical access hospitals.
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.