MGR-UTILIZATION REVIEW ACUTE & CRITICAL ACCESS HOSP

General Purpose of Job:

Reports to the Director of Case Management and is responsible for managing and providing guidance for the daily operations of the utilization management program. This includes activities to assist in the provision of high-quality care to the neonatal, pediatric, adolescent, adult and geriatric patients. Integrates decisions of committees into the operation, oversees the related payer denial, audit and appeal functions, and works to reduce or eliminate the associated risk with payer reimbursement processes. Combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Through continuous assessments, problem identification and education, facilitates the quality of healthcare delivery in the most cost effective and efficient manner.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Caregivers may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.

• Develops, implements, and administers plans for utilization review services in collaboration with the Director of Case Management.
• Collaborates with internal and external customers to coordinate review activities for neonatal, pediatric, adolescent, adult, and geriatric patients in a timely and efficient manner.
• Utilizes approved screening guidelines to evaluate the appropriateness of admission care, continuation of care and discharge.
• Identifies actual and potential problems throughout hospitalization to improve the utilization of hospital resources through appropriate action and recommendations.
• Reviews and provides medical information for patients whose financial reimbursement to the hospital is dependent upon the information being provided to insurers, third party payers. Identifies inappropriate or inaccurate documentation and follows established guidelines for reporting.
• Facilitates and coordinates involvement of medical staff in responding to third party payer requests to ensure positive outcomes and maximal reimbursement of hospital services.
• Utilizes reports and data to support administrative efforts regarding policies, procedures, and best practices.
• Assists with education of medical staff and other health care professionals regarding utilization of resources and regulations that impact the delivery of care.
• Provides input into departmental budget, goals, objectives.
• Develops, maintains, and oversees work schedules, and sets priorities.
• Educates, trains, supervises, counsels and evaluates Sparrow caregivers.
• Provides input related to personnel matters pertaining to employment, training, termination and grievance of employees.
• Performs other related duties as required.
• Ability to function successfully in an extremely challenging environment.