5-10 years of experience in clinical care coordination or utilization management
Strong understanding of DME respiratory services (CPAP, NIV, invasive ventilators)
Proven leadership ability with focus on team development and performance management
Knowledge of CMS regulations, medical necessity criteria, and clinical guidelines
Experience in policy compliance and quality assurance methodologies
Responsibilities
Lead and manage the Clinical Care Coordination and Utilization Management teams
Oversee clinical review and authorization workflows for DME respiratory services
Direct utilization management activities to ensure compliance with CMS turnaround times
Ensure accurate application of medical policies during coverage determinations
Allocate resources efficiently to meet operational demands and maintain quality standards
Facilitate communication with providers, vendors, and stakeholders regarding care coordination
Analyze performance metrics to drive process improvements and enhance patient outcomes
Benefits
Ongoing professional development and training opportunities
Supportive team environment fostering career growth
Commitment to patient-centered care and service excellence
Collaborative work culture with emphasis on effective communication
Focus on compliance with regulatory standards ensuring job security
Full Job Description
What You Will Be Doing
Leadership & Team Management: Provides leadership, direction, and oversight to Clinical Care Coordination and Utilization Management staff supporting DME services. Responsible for recruitment, onboarding, training, performance management, coaching, disciplinary actions, and compensation reviews. Ensures staff consistently meet productivity, quality, compliance, and turnaround time benchmarks.
DME Clinical Oversight (CPAP, NIV, Invasive Ventilators): Oversees clinical review and authorization workflows for DME respiratory services, including CPAP, BiPAP, non-invasive ventilation, and invasive ventilators. Ensures clinical documentation supports medical necessity, appropriate level of care, and alignment with evidence-based guidelines and payer requirements.
Utilization Management Oversight & CMS TAT Compliance: Directs utilization management activities to ensure timely UM reviews and determinations in accordance with CMS, state, and contractual turnaround time requirements for urgent and standard requests. Monitors TAT performance, escalates risks, and implements corrective actions to maintain compliance.
Medical Necessity Review & Decision-Making: Ensures accurate application of medical policies, benefit plans, and clinical criteria when making coverage determinations. Oversees appropriate referral of complex or non-standard cases to the Medical Director in accordance with departmental protocols. Monitors approval, denial, and overturn rates to ensure defensible, compliant decisions.
Resource Allocation & Operational Efficiency: Allocates staff and resources to meet operational demands while maintaining clinical quality and regulatory compliance. Oversees workload distribution, staffing models, and workflow optimization to support timely service delivery within budgetary constraints.
Staff Development, Training & Compliance: Leads ongoing training and competency development for UM and care coordination staff, including CMS regulations, medical necessity criteria, documentation standards, and DME-specific requirements. Ensures adherence to policies, procedures, and compliance KPIs through audits, coaching, and continuous education.
Provider, Vendor & Stakeholder Collaboration: Facilitates effective communication with providers, DME vendors, home health agencies, and payers regarding authorizations, denials, documentation requests, and care coordination needs. Ensures provider inquiries and disputes are resolved within established service level agreements (SLAs).
Performance Monitoring & Process Improvement: Analyzes productivity, quality, cost, denial, and TAT reports to identify trends and improvement opportunities. Leads performance improvement initiatives to enhance efficiency, reduce avoidable denials, support cost containment, and improve patient outcomes.
Policy, Regulatory & Accreditation Compliance: Ensures departmental compliance with CMS regulations, accreditation standards (NCQA, URAC, as applicable), internal policies, and contractual requirements. Supports audits, regulatory reviews, and corrective action plans as needed.
Confidentiality & HIPAA Compliance: Maintains strict adherence to HIPAA and privacy regulations. Ensures staff compliance with confidentiality standards and completion of all required compliance and privacy training.
Join our team as we strive for excellence through teamwork, where our patients are #1!
