Oversees and directs all central utilization management functions. Ensures that all clinical reviews are appropriate, thorough and timely with efficient certification reconciliation processes maintained. Develops collaborative relationships with payers. Acts as a liaison for Managed Care, Revenue Cycle, Care Coordination, all Hospital Departments. The Director of Utilization identifying opportunities and leads projects for improvement from both internal and external sources including regulatory agencies.

SPECIFIC RESPONSIBILITIES AND DUTIES

• Develop, implement and maintain policies and procedures for all UM functions.
• Coordinate efforts between CHS and Facilities Care Management/Coordination Departments to develop efficient workflows and processes.
• Oversee and manage daily UM Department functions and staff.
• Develop collaborative Payer relationships to enhance communication and reconciliation processes.
• Serve as a resource to Care Coordination and other departments for Revenue Cycle and Managed Care issues.
• Identify payer trends that adversely affect utilization and reimbursement cycle.
• Track key metrics with monthly reporting to Leadership
• With Physician Advisors identify and implement educational opportunities for clinical and medical staff
• Prepare utilization reviews for submission to payors, as needed
• Support Director of Appeals, as needed.
• Provides support for ongoing projects as required
• Attends meetings as required and participates on committees as directed.
• Performs other related duties as assigned or requested

POSITION REQUIREMENTS AND QUALIFICATIONS

Education/Experience

• Graduate of an accredited Nursing School or College; current New York State, R.N.
• License required, Bachelor of Science in Nursing or Health preferred.
• Minimum 10+ years of relevant clinical medical-surgical or specialty experience required as applicable to position needs.
•  Experienced clinical reviewer and/or Care Management experience required in an acute hospital or related managed care setting.
• Required to pursue ongoing education, certification and self-development to remain current with industry standards and business objectives related to Care Management as appropriate.

SKILLS

• Sound knowledge and skill in the use of personal computer and software for word processing and spreadsheet required. Experience with EPIC, Midas, Star and other hospital software as required.
• Ability to effectively communicate with all levels of hospital staff in a verbal and written manner; demonstrated ability to be organized and efficient in prioritizing and managing assignments with minimal oversight and direction.
• Demonstrates a courteous and professional demeanor, team spirit and the ability to work in a collaborative, effective manner.
• Seeks clinical expertise/reference for specialty services as needed.
• Demonstrates aptitude and skill in applying sound financial and reimbursement principles to all appeal functions and reporting.
• Ability to utilize critical thinking and apply sound clinical judgment and assessment skills for decision-making.

KNOWLEDGE

• Expert knowledge of MCG, InterQual and other evidence based guidelines as applicable.
• Knowledge of Federal, State and PRO regulations preferred.
• Maintains knowledge of requirements by third party payers, regulatory agencies, and managed care entities concerning levels of care, continuity of benefits and medical necessity guidelines.
• Knowledge of managed care and the current standards and trends of patient care, best practices, management tools.

This range serves as a good faith estimate and actual pay will encompass a number of factors, including a candidates qualifications, skills, competencies and experience. The salary range or rate listed does not include any bonuses/incentive, or other forms of compensation that may be applicable to this job and it does not include the value of benefits.

At Catholic Health, we believe in a people-first approach. In addition to the estimated base pay provided, Catholic Health offers generous benefits packages, generous tuition assistance, a defined benefit pension plan, and a culture that supports professional and educational growth.