- Manages the daily operations of the Utilization Review (UR) and Audit Services departments. Ensures these services are compliant with organizational policies, industry regulations, legal requirements, and payer and contract requirements.
Serves as a subject matter expert for Utilization, Audit Services, and Denial mitigation. Provides support and serves as a liaison and point of contact on these topics for internal and external stakeholders. Maintains positive relationships with internal and external stakeholders, addressing their needs and concerns, as necessary. - Provides effective leadership and guidance to team members, fostering a collaborative and results-driven work environment. Encourages growth and development of the team through education, networking, and specialty certification. Fosters effective communication within the department and across the organization, ensuring alignment with organizational goals.
Responsible for the recruitment, selection, and onboarding of new team members. Assess employee performance and provide feedback. Identify and address training needs, mentor, and coach team members to enhance their skills and knowledge. Conduct performance reviews, set performance goals, provide constructive feedback to team members, and corrective action as required. Participates in divisional and departmental Hoshins by assisting Directors in establishing goals for the department; alignment of those goals with department operations and assists staff in setting goals and meeting standards. Monitors and tracks key performance indicators (KPIs) to assess progress and success in achieving departmental goals. Utilizes Lean continuous improvement principles to reduce waste, improve quality, and drive value for the staff, stakeholders, and the organization. Analyzes and resolves challenges and issues that may arise within the department, making decisions that support productivity and efficiency. Keeps abreast of changing industry requirements and regulations by reviewing the Federal Register, fraud alerts, OIG advisory opinions, and other relevant publications. Communicates changes to impacted leaders and provides education on such changes. Ensures initial and continued stay authorization and review processes are implemented to achieve appropriate levels of patient care and authorizations. Ensures appropriate medical necessity screening tools such as Milliman Care Guidelines (MCG) are utilized. Ensures initial and continued stay authorization and review processes are implemented to achieve appropriate levels of patient care and authorizations. Ensures appropriate medical necessity screening tools such as Milliman Care Guidelines (MCG) are utilized. Ensures clinical reviews for medical necessity and level of care, and benefit reviews rendered in the inpatient and outpatient setting to ensure the patient receives the most appropriate level of care. Monitors for consistent application of UM criteria by staff, for each level and type of UM decision. Ensures UR and Audit work queues are managed as required. Conducts utilization and audit data analysis (avoidable days, readmissions, UMAB, PRS reports, one-day stays, DRGs, LOS, PD Rs, etc.) for trending and development of performance improvement initiatives. Identifies opportunities using contract and denials management tools/techniques, random reviews (including payment accuracy reviews), and reviews of medical records and claims data. Manages, maintains, and communicates to appropriate stakeholder departments relevant denial and appeal activities, trends, and recommended corrective action plans. Prepares data and narrative reports on utilization patterns, patient status accuracy, and denials management as required by program goals and objectives. Refers known or suspected problems of under-utilization over-utilization or inappropriate scheduling of services to the attention of the Medical Director, UM Committee, and Quality Management Department. Examples include avoidable bed days, inappropriate admissions, and delayed procedures. Reviews charge-related patient grievances; reviews denied charges, recommends appeals and/or facilitates the resolution of root causes where appropriate; communicates audit findings to various parties and works closely with a variety of external parties or individuals to resolve disputes. Provides support for annual audits, including financial, payers (i.e., Medicare), and any other agency. Provides a clinical review of the Hospital’s ER Indigent Program to support payments to physicians on billed claims. Reviews transportation services per contractual agreement(s) and provides billing guidance and quality improvement recommendations.
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