Divisional Manager Utilization Management
Job Description
AdventHealth
Internal Number: 25004922
All the benefits and perks you need for you and your family:
·Paid Days Off from Day One
·Student Loan Repayment Program
·Career Development
·Whole Person Wellbeing Resources
·Mental Health Resources and Support
Our promise to you:
Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding thattogetherwe are even better.
Schedule: Full Time
Shift: Days
The community you’ll be caring for:AdventHealth Division
·AdventHealth Pepin Heart Institute, known across the country for its advances in cardiovascular disease prevention, diagnosis, treatment and research.
·Surgical Pioneers – the first in Tampa with the latest robotics in spine surgery
·Building a brand new, six story surgical and patient care tower which will ensure state of the art medical and surgical car for generations to come
·Awarded the Get With The Guidelines – Stroke GOLD Quality Achievement Award from the American Heart Association/American Stroke Association and have been recognized as a recipient of their Target: Stroke Honor Roll for our expertise in stroke care. We have also received certification by The Joint Commission in collaboration with the American Stroke Association as a Primary Stroke Center.
The role you’ll contribute:
The Divisional Manager of Utilization Management (UM) is a registered nurse, who works under the direction of the Divisional Director of Utilization Management, and provides oversight for the strategic direction setting, management, continuous improvement, and maintenance Utilization Management team. The Divisional Manager assists the UM Director in the strategic planning and daily operations of the team members dedicated to obtaining timely authorizations, avoiding unnecessary denials, and ensuring productivity standards are maintained throughout the department. This individual focuses on ensuring efficient productivity, compliant workflows, and clinically appropriate denial prevention across the region that aligns with the AdventHealth mission. This position will provide outstanding service standards and accepts responsibility in maintaining relationships that are equally respectful to all.
The value you’ll bring to the team:
· Evaluates the efficiency, clinical appropriateness, necessity of the use of medical services and procedures in the most resourceful clinical setting under the most appropriate status
· Ensures staffing needs are adequate to support authorization functions, ongoing claim authorizations, utilization management requirements, telephonic utilization management, denial avoidance and intervention activities, and to maintain collaborative workflows with Care Management
· Collaborates with facility level Care Management staff as needed to address and resolve Utilization Management related concerns/issues
· Ensures compliance with both government and contractual guidelines
· Ensures staff compliance with regulatory requirements including but not limited to: Condition Code 44, two-midnight inpatient certification audits, physician orders for correct status level, etc.
· Supports staff in daily pre-admission, admission, concurrent, and/or retrospective utilization reviews (as assigned) by leveraging Cortex logic to determine/support appropriate levels of care
· Maintains working knowledge of payor standards for Utilization Management functions for authorization requirements
· Collaborates with managed care partners and commercial payors to quickly address authorization or medical necessity concerns
· Works collaboratively with Physician Advisors to address status change recommendations, peer-to-peer reviews, and concurrent denial opportunities
· Participates in hospital/medical staff meetings to review patients meeting medical necessity related to high dollar cases seeks assistance from Utilization Management Divisional Director, as needed
· Remains current on denial trends and performs root cause analyses to address issues
· Provides ongoing education and direct clinical case reviews to support the Utilization Management team, as well as facility specific goals to improve Utilization Management, denial avoidance, and compliance with payors and Centers for Medicare & Medicaid Services (CMS)
Qualifications
The expertise and experiences you’ll need to succeed:
· RN, Associate or Diploma Degree
· Clinical experience in acute care facility – greater than three years
· Previous experience in utilization review (minimum two years)
· Previous experience with denials and appeals (minimum one year)
· Experience with precepting/mentoring others (minimum two years)
· RN, Associate or Diploma Degree
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.
Source ⇲
To apply, please visit the following URL:https://jobs.healthcareercenter.com/jobs/rss/21052364/divisional-manager-utilization-management→
