System Director Utilization Management - Primarily Remote

Tufts Medicine

123d

About The Position

This role focuses on activities related to revenue cycle operations such as billing, collections, and payment processing. In addition, this role focuses on performing the following Patient Access duties: Performs the administrative and financial-clearance duties necessary to facilitate the procurement of clinical services by patients. Collects patient's necessary demographic and financial information from physician offices, acute-care entities, or the patients themselves, schedules services for patients, and handles referrals from primary care doctors to ensure patients are scheduled for recommended appointments/procedures, etc. A management role that supervises employees focusing on tactical, operational activities within a specified area, with the majority of time spent overseeing area of responsibility, planning, prioritizing and/or directing the responsibilities of employees. Goal achievement is typically accomplished through performance of direct and/or indirect reports. A role that directs a department or small unit that includes multiple teams led by managers and/or team Leaders. Responsibilities typically include: ownership of short to mid-term (1-3 years) execution of functional strategy and the operational direction of the Department, problems faced are often complex and require extensive investigation and analysis, and requires ability to influence others to accept practices and approaches, and ability to communicate and influence executive leadership.

Requirements

• Bachelor of Science in Nursing (BSN).
• Massachusetts RN Licensure.
• Current certification in case/utilization management (ACM, CCM, CMAC).
• Seven (7) years of UM/Case Management experience in an acute-care hospital or multi-hospital system, including two (2) years of supervisory experience.

Nice To Haves

• Master’s in Nursing.
• Fluent in CMS Two-Midnight, Inpatient-Only, Condition Codes 44 & W2, MOON/IMM, and payer-specific admission guidelines.

Responsibilities

• Serves as the UM first point of contact for Tufts Medicine.
• Responsible for addressing complex issues, processes and root causes such as those stemming from an inability to achieve agreed upon metrics and targets.
• Leads the development of policies to decrease variation in practices for Utilization Management.
• Coordinates the setting of Utilization Management metrics and tracking across the markets.
• Collaborates and meets regularly with Utilization Management, as well as corporate and revenue cycle leaders, to review metrics and discuss any operational issues.
• Coordinates Utilization Management meetings and deliverables.
• Acts as Co-chair System UM Committee Meetings.
• Responsible for resolving issues associated with performance in accordance with the process standards outlined.
• Acts as the first point of contact for addressing any human resource related issues.
• Responsible for facilitating and assigning representative(s) to participate in any UM initiative(s) at the corporate or local level as mutually agreed upon and approved by leadership.
• Ensures adequate staff with the appropriate expertise to deliver timely information and to respond to facility, patient care team and payor inquiries regarding authorization number and authorized days, admission status and review, and concurrent reviews.
• Responsible for daily operations, such as setting leadership behavior and human resources.
• Ensures ongoing collaboration with the Physician Advisor(s) and meet regularly with revenue cycle and finance leadership.
• Available to intervene in cases which fail to meet screening for admission or continued stay due to medically necessary care and/or if there is disagreement between UM RN and attending Physician in determining appropriate patient status.
• Maintains ongoing collaborations and discussions with Clinical Documentation Integrity (CDI) and Coding leadership to review data and identify areas for clinical documentation improvement.
• In the absence of a Physician Advisor, the hospital Chief Medical Officer (CMO) will be consulted.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: Bachelor's degree
• Number of Employees: 1,001-5,000 employees