Utilization Management Director leads and directs the utilization review staff and function for a healthcare facility. Determines policies and procedures that incorporate best practices and ensure effective utilization reviews. Being a Utilization Management Director manages and monitors both concurrent reviews to ensure that the patient is getting the right care in a timely and cost-effective way and retrospective reviews after treatment has been completed. Provides analysis and reports of significant utilization trends, patterns, and impacts to resources. Additionally, Utilization Management Director consults with physicians and other professionals to develop improved utilization of effective and appropriate services. Requires a master's degree. Typically reports to top management. Typically requires Registered Nurse(RN). The Utilization Management Director manages a departmental sub-function within a broader departmental function. Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure. Deep knowledge of the managed sub-function and solid knowledge of the overall departmental function. To be a Utilization Management Director typically requires 5+ years of managerial experience. (Copyright 2024 Salary.com)
$5,000 SIGN ON BONUS
Utilization management (UM) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan.
Prior authorization that allow payers, particularly health insurance companies to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. Strong utilization management process can reduce payment denials.
Clinical documentation specialists is designed to improve the physician’s documentation in the patient’s medical record, supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient.
Clinical documentation is responsible for extensive collaboration with physician is, nursing staff, support staff, other patient caregiver and medical records coding staff.
Employee insurance liaison
Meadville Medical Center has self-funded insurance. One staff member is assigned to work with Human resources, Highmark Liaison, Medical director and employees. Set process is to call medical procedures out of network and employee needs to request a waiver from our current liaison. The liaison will review the requested procedure with our current medical director. If the request is approved the liaison of UM will notify the employee and out Highmark Liaison.
Medical necessity rules will be reviewed, urgency and medical history. The decision will be called to the employee. If it is not favorable, this can be appealed to human resources
If this process is not followed, and the employee gets a bill. The liaison will review what was performed. They will review with the medical director and make a decision to override the out of network rules.
The liaison support HR represented as needed.
Applicate:
Curious and Detailed Oriented. Actively seek out new ideas, possibilities, and answers to the tough questions.
Pays meticulous attention to detail.
Committed to life-long learning
UM Process
score: N/A
CDS-Inpatients
Overall department goals
Promotes improved quality of care and/or life.
Promotes cost effective medical outcomes.
Prevents hospitalization when possible and appropriate.
Promotes decreased lengths of observation stays or inpatient stays when appropriate.
Provides for continuity of care.
Assures appropriate levels of care are received by our patients.
Participates in rounding on the nursing floors.
Works with HIM on coding issues.
Provides advice and counsel to precertification staff in physician offices or in house.
Identifies appropriate alternative resources and demonstrate creativity in managing each case to fully utilize all available resources.
Maintains accurate records of all communications and interventions.
Other duties as assigned.
MINIMUM EDUCATION, KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED
Proof of successful completion of education requirements for board certified registered nurse as defined by the state in which the employee is to practice as well as proof of such licensure in good standing. Must have at least 5 years’ experience as a Registered Nurse.
Ability to read analyze and interpret documents, reports, technical procedures, governmental regulations and correspondence
BLS required.
Certification for UM nurse and CDI specialists is encouraged
0 Utilization Management Director jobs found in Erie, PA area