Utilization Management Director jobs in Binghamton, NY

Job Description

Job Title: System Director of Utilization and Care Management

Department: Clinical Resource Management

Reports To: Senior Director, Care Transitions

Job Summary: Cayuga Health System seeks a highly motivated and goal-oriented Director of Utilization and Care Management responsible for providing oversight and broad direction to Case Management, Social Services, Utilization Management and Clinical Documentation Improvement/Integrity. The System Director of Care and Utilization Management works closely with CHS leadership - in particular Nursing, Patient Access/Accounting, Revenue Cycle, Information Systems, and Performance Optimization - to support patient progression and optimize outcomes affecting clinical, operational, and financial performance.

Job Responsibilities include:

• Monitor and identify trends in practices, utilization, and reimbursement that may present financial risk to CHS; develop plans to reduce/eliminate respective risks.
• Identify educational opportunities for team members to increase understanding of CM/UM concepts and trends, streamline activities, and improve patient outcomes.
• Strategic and proactive hiring, performance management and coaching to enhance professional development and optimization of skillsets.
• Develop, implement, and annually review the CHS Utilization Management Plan; works with provider chairs to facilitate Utilization Review Committee meetings.
• Ensure compliance with business ethics, state and federal regulatory requirements, and organizational policies and procedures among direct reports.
• Evaluation and recommendation of vendor/contractual services to support denial management and other departmental activities.
• Maintain knowledge of complex clinical guidelines and medical management policies published by payers; communicates relevant clinical requirements to ensure documentation is optimal and succinct.
• Demonstrate the willingness and ability to work collaboratively with key internal and external teams, both clinically and administratively to obtain necessary information to promote outcomes and readily address revenue cycle and denial management opportunities and concerns.
• Demonstrate strong written and verbal communication skills. Enforces appropriate written and verbal communication among team members.
• Develop and implement feedback and educational initiatives for denial prevention activities as indicated.
• Work with area supervisors to streamline communications, processes, and role definitions within the department.
• Design and implement process to readily track and report relevant UM/CDI/Denials Management functions inclusive of but not limited to:

• CDI Impact, Query rates and responses

• MOON and IMM Compliance data
• DRG Downgrades
• Length of stay and avoidable delays

• Maintain budgetary duties as assigned.
• Exemplify satisfactory attendance and punctuality record as set forth by CHS policies.
• Exemplify a professional image in appearance, manner and presentation.
• Maintains patient confidentiality in the provision of quality care.
• Is flexible in assuming other appropriate responsibilities not noted above.

Requirements:

Education - Masters of Nursing, Healthcare Administration, or related field required.

Experience - Minimum 5 years of experience in acute hospital setting, minimum of 3 years in leadership. Minimum 3 years of experience with utilization and denials management. Knowledge of discharge planning and clinical case management strategies. Knowledge and experience in project management and team dynamics. Outstanding leadership, analytical, negotiation and conflict resolution skill. Knowledge and experience in developing utilization management and revenue recovery strategies. Highly motivated and goal orient. Demonstrated knowledge and experience in developing utilization management and revenue recovery strategies. Demonstrated ability to implement change and lead effective teams.

Physical - Ability to stand, sit or ambulate for long periods. Ability to mobilize freely around units, transport self to site locations, and perform required data entry into EMR and alternate data management systems.

• Indicates Essential functions

Cayuga Health System Commitment to Diversity, Equity & Inclusion

Cayuga Health System commits to treat all people with dignity so that everyone who comes to us is safe, cared for, and respected. We will support the growth of our employees and the health of our community by embracing the rich diversity of social and cultural identities, needs, and life circumstances of all people. We strive to recognize and overcome personal biases and systemic policies that marginalize others and contribute to disparities in healthcare access, equitable care, and good health outcomes.

Cayuga Health is dedicated to our vision for diversity, equity, and inclusion. As we strive towards our vision, we welcome the opportunity to work alongside a diverse range of employees