Director, Utilization Review

Community Health Systems is a leading operator of general acute care hospitals and outpatient care centers in communities across the United States. CHS affiliates own, lease or operate 84 affiliated hospitals in 16 states with an aggregate of approximately 13,000 licensed beds. Healthcare services are also provided in more than 1,000 outpatient sites of care including affiliated physician practices, urgent care centers, freestanding emergency departments, imaging centers, cancer centers, and ambulatory surgery centers.

CHSPSC, LLC seeks a Director of Utilization Review for its Franklin, TN, headquarters’ Case Management team.

Summary:

Responsible for overall day-to-day operational efficiency and financial success of URCSS. Reports to VP of Case Management to stay connected with corporate functions and meets with Regional Case Management Directors to communicate key trends, process changes, and escalate and address major UR issues. Manages vendor and payor relations when needed. Responsible for performance of UR Managers, Clinical Specialists and Coordinators. If training needs are identified for UR Clinical Specialists or UR Coordinators, responsible for collaboration with Training and Education Specialist(s).

Essential Duties and Responsbilities:

• Provides oversight for the strategic direction setting, management, continues improvement, and maintenance of the Utilization Review team.


• Works in close collaboration with Physician Advisors, Revenue Cycle Leaders, URCSS Business Performance Director, and Case Management leadership to design and implement denial prevention strategies across the regions.


• Provide feedback and support to individual facilities to ensure compliance and optimize outcomes across facilities.


• Evaluates efficiency, clinical appropriateness, necessity of the use of medical services and procedures in the most resourceful clinical setting under the most appropriate status.


• Provides direction and oversight for the day-to-day operations of Utilization Review activities.


• Maintains working knowledge of payor standards for utilization review. Ensures compliance in both government and contractual guidelines. Collaborates with Payor Relations Manager to develop education action plans to address changes in government regulations and contractual changes.


• Acts as a liaison to provider relations issues related to utilization management issues. Develops relationships with physician advisors and works collaboratively to address status changes, peer-to-peer, and concurrent denial opportunities.


• Remains current on denial trends and performs root cause analyses to address. Collaborates with the URCSS Business Performance Director to support dashboard/reporting, solution, and training needs based on trends and common issues.


• Completes employee case evaluations in a timely manner and assesses staff competencies on an ongoing basis.


• Collaborates with Training & Education Specialist(s) to address educational needs for staff.


• Reviews all financial reports available, communicates outcomes to team and leadership timely and manages utilization review budget.


• Performs other duties as assigned.

Qualifications:

• Required Education: Bachelor of Science in Nursing or Healthcare related BS/BA


• Preferred Education: MSN or MBA


• Required Experience: Minimum of 7 years nursing experience and prior experience in Utilization Review or Case Management; 2 years professional leadership and/or management experience


• Preferred Experience: Management level Utilization Review or Case Management experience; previous experience with denials and appeals


• Required License: Current RN license


• Preferred License: ACM or CCM

Computer Skills: Data entry skills; Demonstrable skills with Google Docs, Google Sheets, and email applications.

Physicial Demands: In order to successfully perform this job, with or without a reasonable accommodation, the following are outlined below:

1. The Employee is required to read, review, prepare and analyze written data and figures, using a PC or similar, and should possess visual acuity.

2. The Employee may be required to occasionally climb, push, stand, walk, reach, grasp, kneel, stoop, and/or perform repetitive motions.

3. The Employee is not substantially exposed to adverse environmental conditions and; therefore, job functions are typically performed under conditions such as those found within general office or administrative work.