Utilization Management Director jobs in South Dakota
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)
Recently Added Utilization Management Director jobs
Utilization Management Specialist - RN
- Sanford Health
-
Dakota, SD
FULL_TIME
-
Create Your Career With Us!
Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We're proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint.
Facility: Remote SD (Central Time)
Location: City - Remote SD, SD
Address:
Shift: 8 Hours - Day Shifts
Job Schedule: Full time
Weekly Hours: 40. 00
Salary Range: $24.00 - $38.50
Department Details
Ability to work from home.
Job Summary
Conduct level of care medical necessity reviews within patient s medical records. Performs utilization management (UM) activities in accordance with UM plan to assure compliance with accreditation/regulatory requirements. Completes/coordinates activities relating to the implementation, ongoing evaluation, and improvements to UM and/or prior authorization processes with applicable. Completes activities relating to determination of medical necessity, authorization, continued stay review including diagnosis and procedural coding for working diagnosis related group (DRG) assignments. Workflows may include patient chart review, and assisting with and managing of insurance coverage and denials, prior authorizations, scheduled procedures, same-day readmission reviews, as well as length of stay. Ensure validation of appropriate level of care for pre-admission surgical reviews prior to admission. Reviews include InterQual clinical decision support criteria to ensure both the appropriateness of medical services and effective cost control. Ability to determine appropriate action for referring cases that do not meet departmental standards and require additional secondary review and/or escalation as needed.
May also be actively involved in collaborating with members of the healthcare team to promote medically necessary resource utilization and achievement of fiscal outcomes when appropriate. Collaborates with physicians and other clinical professionals as needed to assist in documentation improvement practices for effective and appropriate services. Dynamic and tactful interpersonal skills, particularly in relating to physicians and other health care professionals. Educates members of the healthcare team regarding trends, external regulations and internal policies that effect resource utilization and potentially, prior authorization.
Assists the department in monitoring the utilization of resources, risk management and quality of care for patients in accordance with guidelines and criteria. Assist in report preparation, correspondence, and maintenance of appropriate records. Ensure services comply with professional standards, national and local coverage determinations (NCD/LCD), centers for Medicare and Medicaid services (CMS), as well as state and federal regulatory requirements. Maintain working knowledge of payer standards for UM functions for authorization requirements.
May assist with additional special projects related to work, upcoming initiatives, new organizational goals and audits when delegated. Considered a resource to all team members and acts as a point of contact for guidance, training, and assisting with questions. Demonstrate flexibility and adaptability where scheduling may fluctuate due to communication needs within interdepartmental and clinical units are required.
Qualifications
Bachelor's degree in nursing preferred. Graduate from a nationally accredited nursing program required, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA).
Currently holds an unencumbered registered nurse (RN) license with the State Board of Nursing. Obtains and subsequently maintains required department specific competencies and certifications.
Benefits
Sanford Health offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, and a generous time off package to maintain a healthy home-work balance. For more information about Total Rewards, visit https://sanfordcareers.com/benefits .
Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-673-0854 or send an email to talent@sanfordhealth.org .
Sanford Health has a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre-employment background screening as a condition of employment.
Req Number: R-0179862
Job Function: Care Coordination
Featured: No - 16 Days Ago
Utilization Management Specialist - RN
- Sanford Health
-
Sioux Falls, SD
FULL_TIME
- Create Your Career With Us! Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We're proud to offer many development and advancement opportuni...
- 17 Days Ago
Utilization Management Specialist
- Sanford Health
-
UNKNOWN, SD
FULL_TIME
- Create Your Career With Us! Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We're proud to offer many development and advancement opportuni...
- 25 Days Ago
Utilization Management Specialist
- Sanford Health
-
Remote, SD
FULL_TIME
- Create Your Career With Us! Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We're proud to offer many development and advancement opportuni...
- 27 Days Ago
Utilization Management Specialist
- Sanford Health
-
Sioux Falls, SD
FULL_TIME
- Create Your Career With Us! Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We're proud to offer many development and advancement opportuni...
- 27 Days Ago
Director, Change Management
- Cox Automotive
-
UNKNOWN, SD
FULL_TIME
- Director, Change Management As the Change Management Director, reporting to the Senior Director of Business Process Design & Improvement or Contact Center Operations and Center of Excellence, you will...
- 19 Days Ago
Utilization Management Director jobs at Popular Companies
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- Oberon Securities, LLC
-
New York, NY
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Managing Director / Senior Managing Director - Debt Advisory
- Oberon Securities Llc
-
New York, NY
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Managing Director
- Transamerica Premier Life Insurance Company
-
Columbia, SC
- The Managing Director is responsible for growing the business of the District Office by developing new quality sales, co...
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Managing Director, Conflict Management & Dispute Resolution
- Dallas College
-
Dallas, TX
- Position Summary The Managing Director of Conflict Management & Dispute Resolution will be responsible for effectively d...
- 4/19/2024 12:00:00 AM
Managing Director, Conflict Management & Dispute Resolution
- Dallas College
-
Dallas, TX
- Position Summary The Managing Director of Conflict Management & Dispute Resolution will be responsible for effectively d...
- 4/18/2024 12:00:00 AM
Utility Management Director
- Hunt
-
Honolulu, HI
- A Brief Overview The Utility Management Director is responsible for providing leadership, direction and guidance as it p...
- 4/16/2024 12:00:00 AM
Managing Director, Product Management
- Omnicom Media Group
-
New York, NY
- Overview Job Description Annalect's 2,000+ innovators leverage data and technology to help clients across Omnicom build ...
- 4/16/2024 12:00:00 AM
Associate Program Management Director/Program Management Director
- MacroGenics, Inc.
-
Rockville, MD
- MacroGenics is a leader in the discovery and development of innovative medicines that utilize our next generation antibo...
- 4/15/2024 12:00:00 AM
About South Dakota
South Dakota (/- dəˈkoʊtə/ (listen)) is a U.S. state in the Midwestern region of the United States. It is named after the Lakota and Dakota Sioux Native American tribes, who compose a large portion of the population and historically dominated the territory. South Dakota is the seventeenth largest by area, but the fifth smallest by population and the 5th least densely populated of the 50 United States. As the southern part of the former Dakota Territory, South Dakota became a state on November 2, 1889, simultaneously with North Dakota. Pierre is the state capital and Sioux Falls, with a populat...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Utilization Management Director jobs
$113,780 to $153,854
Most Popular Cities in South Dakota for Utilization Management Director Jobs
What does a Utilization Management Director do?
Utilization Management Director in Abilene, TX
With an ever-increasing emphasis on reducing costs while still improving patient outcomes, utilization management is taking on new importance.
February 09, 2020
Utilization Management Director in Las Vegas, NV
Read more about the Humana Behavioral Health utilization management process and how it determines patient care.
February 18, 2020
Utilization Management Director in Boise, ID
Provides thought leadership on utilization initiatives and activities to enhance interdepartmental coordination.
December 19, 2019