Bachelor's degree in healthcare administration, nursing, health informatics, business, or a related field (or equivalent management experience).
Three years of direct patient care RN experience in an acute care environment.
Five years of experience in Utilization Review or Case Management in an acute care setting.
Experience with Epic EMR is required.
Certified Professional Coder (CPC) preferred and Certified Case Manager (CCM) or Accredited Case Manager (ACM) must be obtained within two years.
Responsibilities
Supervise Utilization Review, Revenue Integrity, and CDM team members.
Evaluate staff performance to maximize resource efficiency.
Direct Utilization Review activities and implement efficiency measures.
Develop departmental goals to meet organization metrics.
Conduct random audits to assess Utilization Review activities.
Monitor documentation in software platforms for compliance.
Collaborate with peers for timely issue resolution.
Benefits
Opportunities for professional development and continuous improvement.
Access to data and analytics for reporting and strategic planning.
Engagement with clinical and non-clinical teams to foster collaboration.
Work in a critical financial oversight role impacting patient care and organizational success.
Full Job Description
Summary
Provides operational oversight and strategic planning and execution for all areas of the Clinical Revenue Cycle. The Director of Clinical Revenue Cycle is responsible for planning, organizing, coordinating, managing, implementing, evaluating, and developing all areas of the Clinical Revenue Cycle, including but not limited to, Utilization Review, Clinical Appeals, CDM Management, and Revenue Integrity.
This position serves a critical role in acting as a liaison between clinical and non-clinical departments, ensuring positive financial outcomes that match the delivery of care received by patients. Must guide and direct the utilization team to provide optimal financial outcomes for the facility.
This position develops and integrates strategies to ensure financial management, leadership, quality and operational management objectives. The Director functions as the internal resource on issues related to appropriate utilization of resources, coordination of care across the continuum and utilization review and management.
Essential Duties and Responsibilities
These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned.
Supervise the performance of Utilization Review, Revenue Integrity, and CDM team members
Evaluate staff performance and productivity to ensure optimal use of resources
Direct the overall activities of the Utilization Review team and implement efficiency measures
Develop and achieve departmental goals and objectives to ensure organization metric goals are achieved
Perform random audits to ensure appropriateness and timeliness of Utilization Review activities
Monitor documentation in the software platforms for appropriate use
Work closely with peers and leadership team to ensure the timely resolution of issues
Maintain data and metrics to submit to the Revenue Cycle Committee
Report and develop timely reports to submit to the Utilization Management Committee as directed
Review Utilization Review plans annually, revising as necessary, and submit for approval by the Utilization Committee and Medical Executive Committee
Assist with development and maintenance of department budget and ensure that the department operates within the allocated funds
Manages all appeals related to denials for all payers
Implement strategies to reduce denials while optimizing revenue
Ensure all hospitalized patients have the correct admission status so that an appropriate claim can be submitted to the payer
Oversee and coordinate the Utilization Review program's development to include the hospital resources as necessary to support its success
Facilitate and foster staff and physician participation in the development and/or process revenue cycle operations
Engage in improvement activities and events that maximize financial support for the hospital
Communicate Utilization Review results through appropriate committees
Develop and implement a continuous process improvement plan
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. 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.
Education and Experience
Minimum Required Education: Bachelor's degree in healthcare administration, nursing, health informatics, business, or a related field. Five years of management experience will be considered in lieu of degree.
Preferred Education: Master's degree
Experience: Three (3) years of experience in direct patient care RN experience in an acute care environment. Five (5) years of experience in Utilization Review or Case Management department performing utilization review activities, with at least two (2) years of utilization review for an acute care environment.
Certified Professional Coder (CPC) preferred
Certified Case Manager (CCM) or Accredited Case Manager (ACM) within 2 years of eligibility
Experience with Epic EMR is required
Certificates, Licenses, Registrations
If the degree is in Nursing, an active RN license is required
