Manager, Central Utilization Review- Full Time, Days, 8 AM - 4 PM, Morristown NJ

Atlantic Health System•Morristown, NJ

6d•$61 - $108•Onsite

About The Position

This role leads AHS clinical denial prevention and management initiatives to support the appropriate level of care. The Manager works closely with AHS revenue cycle leaders to complete current state assessments, evaluate, and implement leading practices for system standards and/or local market programs. This includes evaluating clinical denials and appeals data, documentation, and workflows to identify and address process and performance gaps. The position also leads successful denials prevention and performance improvement for AHS hospitals, monitoring and managing hospital performance to targets and leading corrective action plans. Collaboration with the Executive Director of Case Management is key to address barriers and gaps in utilization review and authorization confirmation services, providing hospitals with performance data analytics for decision-making and improvement. The role involves working with Managed Care Contracting to identify and address payer and Independent Review Organization (IRO) issues, collecting and collating data from hospitals on payer issues and IRO results, and providing data to the AHS managed care leadership team to address issues with payers. The Manager also provides oversight for appeals assigned to the Physician Advisor (PA) and potential account downgrades, supporting the development and implementation of clinical appeals workflow. This role utilizes tools to address performance barriers, develops and implements best practices, and oversees the implementation of action plans, monitoring progress toward goals. Collaboration with medical and nursing leadership, as well as case management members, is essential to develop and implement methods to optimize the use of hospital and post-acute services. The Manager leads multi-disciplinary process improvement by utilizing excellent communication and servant leadership skills to challenge the status quo and positively influence administrative teams and physicians to change processes to improve performance. Additionally, the role provides analysis and education regarding regulatory and clinical changes impacting inpatient and post-acute care processes and reimbursement, and provides education and tools for physicians and staff regarding programs and processes. The Manager works in alignment with hospital and revenue cycle leadership teams and consistently demonstrates the ability to conduct financial analysis, develop business plans, secure approval for programs, develop strategies to manage and prevent disputes, improve revenue cycle processes, build trusting relationships, lead cross-functional teams, identify process inefficiencies via root cause analysis, design workflows, develop and implement action plans, and implement targeted process changes with ongoing metric monitoring.

Requirements

Graduate of an accredited school of nursing.
Advanced degree in Business, Nursing and/or Health Care Administration required.
Leadership experience care and management of acute hospitalized patients.
Experience in acute care case management.
Current state license as a Registered Nurse.

Nice To Haves

Case management training from a professional Case Management organization, preferred.
ACMA or CCM preferred.

Responsibilities

Lead AHS clinical denial prevention and management initiatives to support appropriate level of care.
Complete current state assessment, evaluate, and implement leading practices for system standards and/or local market programs needed.
Evaluate clinical denials and appeals data, documentation, and workflows to identify and address process and performance gaps.
Lead successful denials prevention and performance improvement for AHS hospitals.
Monitor and manage AHS hospital performance to targets and lead corrective action plans needed to achieve organizational targets.
Collaborate with Executive Director of Case Management to address barriers and gaps in utilization review and authorization confirmation services.
Provide hospitals with performance data analytics to make decisions and drive improvement.
Work with hospital and market leaders to identify when improvement plan is needed and follows up to ensure successful execution.
Work with Managed Care Contracting to identify and address payer and Independent Review Organization (IRO) issues.
Collect and collate data from hospitals on payer issues and IRO results.
Provide AHS managed care leadership team with data to address issues with payers including avoidable days, contract violations, and process issues.
Provide input to contract language to support AHS case management service needs.
Participate with AHS Appeals with Physician Advisor in identifying and addressing trends with payor medical directors.
Provide oversight for appeals assigned to the Physician Advisor (PA) and potential account downgrades.
Support the development and implementation of clinical appeals workflow to incorporate AHS Appeals PA review prior to any account downgrade.
Work with Conifer and Tenet Appeals PA to identify opportunities for improvement including documentation and process.
Utilize findings for process improvement and hospital PA and case management education.
Identify trends to address with managed care contracting and plan medical directors.
Use tools to address performance barriers.
Develop and implement best practices to achieve organizational goals through effectively leading and managing change in a matrix environment.
Oversee the implementation of action plans and monitor progress toward goals assisting with addressing barriers and challenges and adjusting as needed in a supportive, synergistic manner.
Collaborate with medical and nursing leadership, as well as case management members to develop and implement methods to optimize use of hospital and post-acute services.
Manage multi-disciplinary process improvement by utilizing excellent communication and servant leadership skills to challenge status quo and positively influence administrative teams and physicians to change processes to improve performance.
Provide analysis and education regarding regulatory and clinical changes impacting inpatient and post-acute care processes and reimbursement.
Provide education and tools for educating physicians and staff regarding programs and processes.
Conduct financial analysis, develop business plans and secure approval for programs.
Develop strategies to manage and prevent disputes and improve revenue cycle processes.
Build trusting relationships with hospital and revenue leaders to successfully implement new programs.
Build collaborative partnerships and lead cross functional teams to execute on plans and proposals.
Identify process inefficiencies via root cause analysis and design workflow to address opportunities identified.
Develop and implement action plans managing follow up to achieve outcomes.
Implement targeted process changes including ongoing metric monitoring and management to achieve goals and drive improvement.

Benefits

Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members)
Life & AD&D Insurance.
Short-Term and Long-Term Disability (with options to supplement)
403(b) Retirement Plan: Employer match, additional non-elective contribution
PTO & Paid Sick Leave
Tuition Assistance, Advancement & Academic Advising
Parental, Adoption, Surrogacy Leave
Backup and On-Site Childcare
Well-Being Rewards
Employee Assistance Program (EAP)
Fertility Benefits, Healthy Pregnancy Program
Flexible Spending & Commuter Accounts
Pet, Home & Auto, Identity Theft and Legal Insurance