Utilization Review Manager

Hennepin County Medical Center • Minneapolis, MN

83d

About The Position

We are currently seeking a Utilization Review Manager to join our Transitional Care Team. This is a full-time role. The purpose of this position is to manage the design, development, implementation, and monitoring of utilization review functions. The manager oversees daily operations, which include supervising staff performing utilization management activities. The goal is to achieve clinical, financial, and utilization goals through effective management, communication, and role modeling. The manager functions as the internal resource on issues related to the appropriate utilization of resources, coordination of payer communication, and utilization review and management. Responsibilities include carrying out duties in a manner to assure success in financial management, human resources management, leadership, quality, and operational management objectives. The manager participates in program development and UR Department performance improvement and is responsible for day-to-day operations of the department, assists with the budgeting process, personnel recruitment, retention, corrective action, and professional development.

Requirements

• Master's degree in nursing or related field
• Bachelor's degree in Nursing from an accredited program if the Master's degree is in a related field
• Three to five (3 to 5) years of professional leadership experience
• Five (5) years clinical experience
• A minimum of one (1) year of utilization review experience

Nice To Haves

• Masters' degree
• Experience in surgery, emergency and/or critical care
• Experience in process/quality improvement, quality measurement, data abstraction, data analysis and reporting, and data integrity

Responsibilities

• Participates in the development and management of department budgets and productivity targets
• Directs and manages team of UR Coordinators, promotes employee satisfaction, supports staff development, and utilizes the progressive discipline process when appropriate
• Collaborates with department director and professional development specialist to develop standard work and expectations for the utilization review process, including timely medical necessity screening
• 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 Coordinators and Clinical Coordinators identify, document, and communicate avoidable days and delays in services that may prolong length of stay
• Partners with hospital Director Transitional Care to report avoidable days, trends, and actions to UR Committees, as appropriate
• Partners with Physician Advisor 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 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
• Serves as the internal expert on documentation and reimbursement requirements
• 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 This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Industry: Ambulatory Health Care Services
• Education Level: Master's degree