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Overview
Responsible for Inpatient Utilization Management function for Riverside Health System's Acute Care Hospitals. Responsible for overall policy and operational accountability for utilization review to meet system strategic goals and directions. Oversees team members with responsibility for all utilization review activities including monitoring all admissions, concurrent, retrospective and denial reviews, and communicating the patient's plan of care to insurance companies. Partners with Physician Advisor staff as indicated and is responsible for all UM Committee Meetings. Maintains accuracy to track all claims, runs productivity reports, and ensures the timely entry of information related to coordination of reviews in all appropriate systems. Develops and revises policies and procedures, monitors performance, coaches and counsels staff. Participates in process improvement, survey preparedness, insurer collaboration and system/hospital committees.
What you will do
- Provides direct oversight to UM Nurse Care Management team members. Monitors adherence to policies and procedures, evaluates critical thinking and complex decision making skills. Collaborates with Inpatient Care Management Leadership teams, and revenue cycle team members.
- Responsible for the annual budget process to include appropriate resource allocations for FTE’s, skill mix, replacement, succession planning, capital expenditures, and expenses. Completes variance review, analysis and action plans for budget objectives.
- Ensures that annual competencies are completed. Schedules staff for maximum effectiveness to achieve system and facility goals. Ensures department remains current with regulatory changes that impact UM.
- Provides oversight of UM RN's and appeal nurses who manage all concurrent and retrospective denials. Collaborates with the physicians/physician advisors to ensure compliance with issues relevant to non-covered/possible denials. Obtains appeal information from payer, including peer-to-peer information, provides the information to the attending physician, the patient, and the Care Management Leadership, and documents appeal information in Electronic Health Record + Certification Entry Screen. Documents outcomes and steps for next level of appeal.
- Maintains knowledge and provide staff trainings to share the understanding of Medicare/Medicaid regulatory requirements and conditions of participation. Maintains knowledge and understanding of Managed Care and other Payer requirements for appropriate level of care and necessity of continued stay. Defines department scope and practice utilizing guiding principles from ACMA Hospital Case management.
Qualifications
Education
- Masters Degree, Nursing, Business, Healthcare Administration or related field (Required)
Experience
- 5-6 years Case Management or Utilization Review in acute care setting (Required)
- 3-4 years Supervisory experience (Required)
Licenses and Certifications
- Registered Nurse (RN) - Virginia Department of Health Professions (VDHP) Upon Hire(Required)
- Accredited Case Manager (ACM) - American Case Management Association (ACMA) within 1 Year(Required) or
- Certified Case Manager (CCM) - Commission for Case Manager Certification within 1 Year(Required)
To learn more about being a team member with Riverside Health System visit us at https://www.riversideonline.com/careers.
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