Manager - Utilization Review

SUMMARY

We are currently seeking a Utilization Review Manager to join our Transitional Care Team. This is a full‑time role and will be required to work onsite.

Purpose of this position: Manages the design, development, implementation, and monitoring of utilization review functions. Oversees daily operations, which include supervising staff performing utilization management activities. The goal is to achieve clinical, financial, and utilization goals through effective management, communication, and role modeling. Functions as the internal resource on issues related to the appropriate utilization of resources, coordination of payer communication, and utilization review and management.

Responsible for carrying out duties in a manner to assure success in financial management, human resources management, leadership, quality, and operational management objectives. Participates in program development and UR Department performance improvement. Responsible for day‑to‑day operations of the department, assists with the budgeting process, assists with personnel recruitment, retention, corrective action, and professional development.

• Participates in the development and management of department budgets and productivity targets
• Directs and manages team of UR Coordinators, promotes employee satisfaction, supports staff development, and utilizes the progressive discipline process when appropriate
• Collaborates with department director and professional development specialist to develop standard work and expectations for the utilization review process, including timely medical necessity screening to ensure patients are placed at the appropriate patient status and level of care, professional communication with physicians and nurses and other members of the care team
• Collaborates with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status
• Ensures processes are in place for proactive reviews of surgical and other procedures to confirm accurate perioperative pre‑authorization and patient class order reconciliation process. Assesses compliance to regulatory and health plan requirements for authorization, including Medicare
  Inpatient Only List and communicates to provider to obtain accurate order prior to procedure and post procedure
• Ensures UR Coordinators and Clinical Coordinators identify, document, and communicate avoidable days and delays in services that may prolong length of stay; analyzes data to monitor trends for opportunities to improve services. Partners with hospital Director Transitional Care to report avoidable days, trends, and actions to UR Committees, as appropriate
• Partners with Physician Advisor to engage in second level review and working with attending physicians to document completely to ensure patient class determinations
• Serves as expert resource for all Medicare Notification Letters and ensures appropriate distribution of all letters (IMM, MOON, HINN, etc.) including full documentation to meet regulatory requirements and ensure correct billing
• Works collaboratively with Inpatient Care Management, Patient Accounting, Patient Admission and Registration, HIM, and the Finance Department to analyze one‑day Medicare inpatient stays and identify opportunities to improve
• Develops and implements process to manage and respond to all concurrent and post‑discharge third‑party payer denials of outpatient and inpatient cases alleged to be medically inappropriate. Including, but not limited to;
  Peer‑to‑Peer as appropriate, written appeal letters when indicated, documentation of interventions and outcomes and monitor to identify opportunities to improve processes for denial
  prevention
• Serves as the internal expert on documentation and reimbursement requirements. Serves as a resource to the health care team for utilization and denial management. Liaises with provider office staff and facilitates meetings with payers, as appropriate
• May participate in the Utilization Review Committee to present medical necessity data and outcomes and partners with care management leadership to develop action plans…