Director Utilization Management
About The Position
The Utilization Management (UM) Director is responsible for the market(s) development, implementation, evaluation and direction of the Utilization Management Program and staff in support of the CommonSpirit Health Care Coordination model. The Utilization Management department processes authorizations, inpatient admission and continued stay reviews, retrospective authorizations utilizing standardized criteria to determine medical necessity; reviews and processes concurrent denials that require medical necessity determinations; processes appeals and reconsiderations. In collaboration with the Division Director Care Coordination, the UM Director develops strategies to achieve departmental and CommonSpirit Health goals and objectives. This position directs the UM staff to meet or exceed operational performance standards. The Director oversees development and implementation of UM policies, procedures and processes; directs and assists with accreditation activities; efficient management of payer requirements, addressing denials effectively, and compliance with payer and regulatory requirements, and reviews and analyzes UM program outcomes and quality metrics.
Requirements
- Bachelor's degree in Nursing, Health Care Administration or advanced clinical degree.
- Minimum 3 years of clinical case management (Utilization Management, Denial Management, Care Coordination).
- 5 years of progressively responsible management experience.
- Extensive operational experience in managed care.
- Extensive experience in program planning, implementation, staff development, and needs assessment.
- Comprehensive knowledge of utilization management.
- Comprehensive knowledge of financial management that includes revenue cycle.
- Comprehensive knowledge of Medicare, Medicaid, and commercial admission and review requirements.
Responsibilities
- Develop, implement, evaluate, and direct the Utilization Management Program and staff.
- Process authorizations, inpatient admission and continued stay reviews, and retrospective authorizations.
- Determine medical necessity using standardized criteria.
- Review and process concurrent denials requiring medical necessity determinations.
- Process appeals and reconsiderations.
- Develop strategies to achieve departmental and CommonSpirit Health goals and objectives in collaboration with the Division Director Care Coordination.
- Direct UM staff to meet or exceed operational performance standards.
- Oversee the development and implementation of UM policies, procedures, and processes.
- Direct and assist with accreditation activities.
- Manage payer requirements efficiently.
- Address denials effectively.
- Ensure compliance with payer and regulatory requirements.
- Review and analyze UM program outcomes and quality metrics.
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What This Job Offers
Job Type
Full-time
Career Level
Director
