1. Supervises professional and clerical employees who work with a range of functions, including but not limited to: access, pre-authorization and precertification, bed placement, coding, utilization review, and denial management, care coordination collaborative treatment planning and core measures, discharge planning, clinical social work, tracking of the post-acute period and provision of disease management, and contracting internally and externally. 
2. Partners with the CMO for effective relationships with physicians, services, specialties, etc. 
3. Provides consultation to the executive team, forming effective relationships with all VPs and department leaders. 
4. Participates in the determination and definition of the Care Management Dashboard, using data to better understand the strengths and weaknesses of the hospital and department and to determine needs, decisions, and strategies. 
5. Establishes, implements, and evaluates a written strategic plan for the department that takes into account internal and external factors. 
6. Establishes, manages, and constantly evaluates staffing levels, assignments, skills, learning needs, and deployment of staff. 
7. Creates stable and reliable processes to anticipate and address specific situations within the department and between the department and other departments and agencies. 
8. Establishes effective communication systems and forums with third-party payers, the local PRO/QIO, Medical Records, and the managed care and finance offices.
9. Develops structures and processes to facilitate participation by physicians, physical therapists, social workers,   and other health professionals in multidisciplinary care planning, care delivery, and discharge planning. 
10. Participates in continuous quality improvement groups. 
11. Negotiates, approves and manages the operational and capital budgets. 
12. Writes and conducts annual and interim performance appraisals for all staff in the department.

Essential Job Functions:

• Develops, implements, and evaluates denial management strategies and takes action to reduce denials and recover appropriate revenue. Maintains effective tracking mechanism for stages of appeals and final determination notices. 
• Actively participates in revenue activities related to clinical care delivery. Facilitates the flow of information between financial departments and clinical departments regarding changes in payer requirements and recommendations for changes in clinical/operational processes. 
• Develops effective working relationships with regional representatives for payers. Maintains criteria as a framework for negotiating authorization and structuring appeals. 
• Develops, implements, and evaluates 30-day readmissions, length of stay, and cost reduction strategies throughout the health system. Ensures that the team embraces the goals set forth in the budget and actions taken to move the organization toward goal achievement. 
• Develops, implements, and evaluates the discharge planning process for the health system. Takes action to ensure an interdisciplinary approach is evident and that patients are discharged to the appropriate and safe level of care. 

Who Will Be a Great Fit?  

• Bachelor's degree in Nursing (BSN), Masters preferred
• Active New York State License to practice as a Registered Professional Nurse
• 5+ years of RN experience.
• 3+ years of experience in utilization management or denial management.  
• Knowledge and experience in developing utilization management and revenue recovery strategies.
• Experience dealing with authorizations and appeals processes.
• Knowledge of discharge planning and clinical case management strategies.
• Knowledge and experience in project management and team dynamics.
• Knowledge of and experience with basic research methods and statistical analysis.
• DRGs, Medicare Regulations, Medical Necessity Criteria, Patient Bill of Rights, HIPAA

 

As recruiters, we are skilled in our field and understand how to match an opportunity with the individual. If you choose to send us your resume, be advised we will not share it with any employer without your permission. 

If this isn't the right position for you, please share it with someone who might be interested. In the meantime, please look at our website – we have other openings that may suit your needs!

Thank you,

Brian Hughes
https://www.greatbaystaffing.com