Director Utilization Management, Downers Grove, IL
This System Director of Utilization Management will be accountable for the operations and integration of all Utilization review activities. This role is responsible for developing and monitoring strategies at the system level to ensure work processes are efficient and streamlined to improve the revenue cycle. The Director of Utilization Management is responsible for the continuous review of processes and outcomes in order to develop timely response to payer demands and ensure reimbursement for services provided. This role will serve as a subject matter expert related to Utilization Management activities, and provide support to the centralized functions, as well as the individual sites of care, including insights into the individual UM plans and strategies for management of utilization efforts across the system. This role will interact with key areas that impact the medical necessity and the revenue cycle i.e. SRCO, VP of Finance, Contracting, Site's Utilization Management Committee, Nursing, Care Management and Physician Advisors
This position has key responsibility for the utilization review process including admission, concurrent and retrospective review of cases to evaluate medical necessity, quality of care, and appropriate utilization of resources for Advocate Health Care Hospitals. This position monitors the uniform compliance with admission and appropriate level of care criteria and develops strategy to ensure continuing quality improvement activities related to the Utilization Review process and patient safety. This position ensures efficiency of the workflow for team members, and ensures quality cost effectiveness. This position is responsible for working to maintain the revenue integrity by monitoring and managing denial trends, to improve up~front processes to mitigate future denials. The Director of Utilization Management communicates and collaborates with external partners, including regulatory agencies, and payers to ensure compliance and optimize relationships and reimbursement.
System oversight for the utilization management operations for Advocate Health Care Hospitals that are a part of the comprehensive care management program. Responsible for organizing, planning, and directing the clinical and administrative functions and activities in accordance with the system vision and mission in collaboration with Administrator, Care Management Operations/Utilization Management.
Maintains competencies and industry knowledge expertise
Responsible for proactive identification, analysis, implementation, and evaluation of utilization review process improvement opportunities. Develops strategies within the UM program, and in collaboration with the overall revenue cycle, to meet changing needs of health care finance to improve revenue capture and reimbursement.
- Masters degree in nursing or health related field.
- Licensure as an RN.
- 5 years clinical experience and 5 years of experience in utilization/case management.
- 5 + years of Supervisory Experience in Care Management or Utilization management
- Expert knowledge of utilization/case management and managed care.
- Expert knowledge of CMS/other applicable regulatory requirements.
- Expert knowledge of process improvement and strategic methodology.
- Demonstrated leadership ability.
- Demonstrated flexibility, teamwork, and systems thinking.
- Ability to use and manage technology as needed.
- Excellent relationship building skills.
- Excellent written/verbal communication skills.
- Occasionally requires carrying weights of 8 lbs (laptop).
- Resiliency and flexibility to work within a rapidly changing environment.
- Ability to travel periodically to other Advocate sites.
- Urgent/emergency responsiveness to regulatory requests, patient compliants and patient safety events.
- Expertise in relationship building.
- Expert organizational skills.