In partnership with the senior leadership for Care Management, responsible for the implementation and support of the strategic vision for the Central Office Services of utilization review, denials management, and revenue integrity as it relates to care management activities. Advances operational performance through process and service delivery improvements.
1. Ensures that centralized utilization management services, which include utilization review/charge capture/one day stay audits/denials management, are delivered in accordance with regulatory standards and evidence-based guidelines.
2. Effectively promote efficient, accurate and appropriate utilization of InterQual, MCG, and Epic for daily utilization and denials management practices.
3. Coordinate with leadership in utilization management, revenue cycle, and clinical denials to identify and track clinical denials, payor-related issues and trends, identify root cause issues, and implement process improvements to minimize risks.
4. Effectively collaborates with hospital Care Management leadership and Revenue Cycle to ensure issues are addressed in a timely manner, and that core functions & processes align.
5. Communicate and address operational issues in conjunction with Central Services supervisory staff that may be impeding the utilization management and denial review and appeal processes.
6. Ensure appropriate and timely utilization of outside vendors, i.e. MedManagement and Appeal Masters.
7. Work collaboratively with Central Services supervisory staff and the Epic team to identify opportunities for improvement in work queues and workflows within Epic and facilitate those improvements to completion.
8. Oversees the accuracy, collection, and reporting of key metrics for department scorecards and other monthly operating reports.
MINIMUM EDUCATION REQUIRED:
Bachelor’s degree from a recognized college or university is required.
MINIMUM EXPERIENCE REQUIRED:
Seven (7) years of progressive experience in care management/utilization review/denials management with at least two (2) of these years in a management or leadership role.
MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
Applicable licensure for background.
Master’s degree in nursing, social work, business administration preferred.
Hospital and payor experience desired.
Previous experience with or an understanding of working in an Epic environment desired.
Diversity & Inclusion
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