Director Patient Management and Utilization Review
Location: Larkin Bldg @ Exchange Street
Location of Job: US:NY:Buffalo
Work Type: Full-Time
Shift 1
Job Description
Provides oversight and strategic leadership over the Patient Management and Utilization Review Departments across all sites. Includes Case Management, Utilization Review, and Social Work services. Responsible for oversight, standardization, and process improvement to insure appropriate inpatient admission, level of care placement, coordination and receipt of services, psychosocial support, and safe, timely discharge planning and transitions of care across the continuum. Ensures effective interdisciplinary collaboration to address clinical, social, and resource needs, reduce barriers to care, and support optimal patient outcomes.
Responsible for oversight of inpatient and transitional case management functions, including care progression, length-of-stay management, readmission reduction strategies, and post-acute care coordination. Provides leadership for Social Work services to ensure assessment and intervention related to psychosocial needs, discharge barriers, community resource linkage, and support for patients and families throughout hospitalization and transition.
For Utilization Review and Utilization Management, ensures consistent practice and issuance of admission denials, concurrent denial notices, level of care determinations, ensuring patients are afforded appeal rights and financial responsibility is appropriately assigned as part of the broader system utilization management strategy.
Responsible for timely concurrent and retrospective medical necessity appeals and denial management for all lines of business including quarterly insurance company audits, CMS RAC /MAC determinations. Responsible for review of data, determining trends, making recommendations to Senior Financial Team, implementing changes to meet demands. Works closely with Compliance to meet CMS, DOH & DNV regulations.
Education And Credentials
Bachelor's in Nursing, Healthcare, Healthcare Admin or similar required. Registered Nurse NYS licensure required upon hire. Certification in Case Management or Hospital Leadership/Management preferred.
Experience
5 years of experience in Acute Hospital Case Management, Utilization Management, Discharge Planning required. 3 yeasr of experience in management role of Case Management and Utilization Review Departments required. 3 years of experience in EMR, Microsoft Office, MCG criteria required.
Working Conditions
Essential:
* Weight Requirement - Sedentary (10 lbs)
Job Details
Department: BGMC Utilization Review
Standard Hours Bi-Weekly: 0.00
Weekend/Holiday Requirement: No
On Call Required: No
With Rotation:
Scheduled Work Hours: 8a-4p
Work Arrangement: Onsite
Union Code: N00 - Non Union KH
Requisition ID#: 17678
Recruiter: Casey M. Calandra
Grade: EX218
Pay Frequency: Bi-Weekly
Salary Range: $114,338.25 - $157,212.41
*Wage will be determined based on factors such as candidate's experience, qualifications, internal equity, and any applicable collective bargaining agreement.
