Director Utilization Management

Company: Crozer-Keystone Health System
Location: Springfield
Posted on: February 23, 2021

Job Description:

FR =Full-time Regular , 1 =Day Shift , 8:30am-5:00 pm Job Summary: The Director, Utilization Management (UM) leads and directs the utilization review staff and functions for the organization. The Director, UM identifies policies and procedures that incorporate best practices and ensure effective utilization reviews that meet required timeframes. The Director, UM is responsible for the daily management and oversight of major lines of utilization (inpatient, skilled nursing facilities, procedures, radiology etc.), and prior authorizations for Coordinated Regional Care's (CRC) delegated lines of business. The Director, UM, manages and monitors concurrent and retrospective reviews to ensure that the patient is receiving the right care in a timely, high-quality, and cost-effective manner. The Director, UM will lead interaction with Crozer Health Hospital Care Management and UM staff to educate hospital Care Management, UM staff, and providers about health plans, NCQA, CMS/PA State, and Medical Group best practices and regulations. The Director will develop quarterly and annual plans in consultation with the Chief Medical Officer, Medical Director, and practice physicians to improve utilization of effective and appropriate services.

• Develop and promote a fully-integrated approach to UM to include prior authorization and concurrent/retrospective reviews while improving quality of care and managing ER/IP costs and reduction in overall costs.
• Oversee a team of UM nurses and coordinators to execute and improve UM processes. Stay closely involved in day-to-day process to understand and improve UM processes and ensure team fulfills mandated guidelines.
• Manage and monitor UM processes to ensure compliance with PA State and NCQA or payor mandated timeframes for authorization determinations, as well as patient and physician verbal and written communications.
• Develop and enhance programs to optimize collaboration between internal and external nurse case managers and primary care physician staff to achieve enterprise medical management targets and to meet departmental objectives and metrics.
• Ensure compliance with all applicable regulatory and accreditation guidelines such as NCQA, CMS, and PA Health Choices program
• Responsible for meeting timeframes for UM report generation and submission.
• Mentor direct reports to meet department and company objectives.
• Facilitate and lead scheduled Utilization Management Committee meetings.
• Attend Crozer Health and Hospital JOC's when requested and ensure action items are followed-up and resolved.
• Attend and participate in operational or interdepartmental meetings a requested. Develop policy and procedures as required for departmental improvements.
• Complete special projects when required or needed. Qualification Requirements: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. This job description reflects management's assignment of essential functions; it does not prescribe or restrict the tasks that may be assigned. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Ability to demonstrate effective critical things and decision-making skills. Demonstrate ability to manage multiple priorities within time constraints. Stays focused with pressure. Strong written and verbal communication skills. Education/Experience: PA license eligible Registered Nurse with minimum of 5-10 years' experience in managed care or Health Plan environment; preferred Utilization Management, Quality Improvement, Inpatient Program, and Health Plan Incentive program experience. Deep understanding of the UM process, statutory and regulatory requirements, and UM Appeal/Grievance processes. Experienced with Health plan guidelines and Interqual criterion, PA State guidelines, and community guidelines and practices. Strong background in UM in acute hospital setting and Emergency Department. PA license must active and in good standing at time of hire. Knowledge/Skills/Abilities: Strong computer skills, data entry, and proficient in Word, Excel, Access, Power Point. Proven success in working and managing employees in a UM operation. Strong leadership skills in managing UM related work group and achieving organizational goals. Strong independent decision-making, influencing and analytical skills. Extensive knowledge of state and federal laws and regulations governing medical agencies. Strong organizational and problem solving skills. Ability to work effectively under pressure by prioritizing work activities. Maintains member confidence and protects operations by keeping claim and patient information confidential in compliance with HIPAA requirements.

Keywords: Crozer-Keystone Health System, Springfield , Director Utilization Management, Executive , Springfield, Massachusetts