Director of Utilization Mgmt

Job Summary

The Director of Utilization Management is responsible for planning, organizing, developing, and directing implementation of the hospital's Utilization Review Plan and the overall operation of the Utilization Management Department in accordance with federal, state and local guidelines, regulatory agencies, and hospital contractual payor agreements.  In a dyad with the Medical Director of Utilization Management, is responsible for the quality, effectiveness, and efficiency of utilization review processes inclusive of prior authorization, concurrent and respective review, transitions of care, readmission reduction, hospital resource utilization and payer denial mitigation. This position works with hospital leadership to coordinate and integrate utilization management activities, using continuous quality improvement initiatives to promote positive patient outcomes. Coordinates data collection and reporting to verify outcomes, effectiveness of utilization management activities and appropriate use of resources, to achieve appropriate length of stay and level of care, while promoting cost effective and quality patient care. 

Minimum Qualifications

Minimum Education: Master's Degree in Nursing, Healthcare Administration or Related Field
Minimum Years of Experience: 5 Years of clinical experience in an acute care facility;
5 Years of management experience in Utilization Management, in a managed care environment or healthcare industry, which may be concurrent
Substitutable Education & Experience (Optional): Applicants will be considered if they are enrolled in an applicable Master's Degree program with the expectation they have attained their master's degree within 12 months of hire//promotion into the role
Required Certifications/Licensure: Current RN license to practice in the State of South Carolina;
National certification in Case Management or other related certification (national certification may be obtained within 12 months of hire/promotion into the role 
Required Training: Knowledgeable of Admission, Continued-Stay and Discharge criteria and case management

Essential Functions

• Facilitates the provision of patient centered care through the use of best practice to identify and implement process and system improvements.
  • a. Coordinates concurrent record review to determine medical necessity of admission and appropriateness of continued hospitalization according to pre-established criteria.
  • b. Establishes processes for staff within department to participate in patient care         conferences.
  • c. Develops department goals and objectives, and establishes and implements policies and procedures for department operation.
  • d. Implements measures to assure efficient and timely use of hospital resources.
  • e. Assures that personnel work well together to support physician, nursing and social work staff and meet patient/family needs.
  • f. Monitors and leads team in support and planning for patients with life limiting disease.
  • g. Supports initiatives to improve throughput and reduce medically unnecessary         readmissions.
• Assesses human resource needs and plan and evaluate employee activities to ensure safe, effective and fiscally sound operations.
  • a. Develops standards of performance for staff within the department, conducts performance appraisals and oversees disciplinary actions within the department. 
  • b. Responsible for development and adherence of FTE budget.
  • c. Knowledgeable of HR processes and uses HR personnel appropriately.
  • d. Promotes continual learning environment which provides opportunities for the continued professional development and broadened clinical knowledge of staff. 
  • e. Works closely with the medical staff, hospital departments and administration.
  • f. Implements measures to assure productivity and efficient use of resources within         department.
• Evaluates, selects, utilizes and accounts for material resources with appropriate consideration for patient/staff needs, hospital policies and procedures and budgetary constraints.
  • a. Responsible for the development and adherence to operating and capital budget based on projected needs and constraints.
  • b. Evaluates and monitors the utilization of appropriate resources based on analysis of needs.
  • c. Keeps abreast of current trends and innovations in material resources through benchmarking and other cooperative activities.
  • d. Implements systems to streamline and provide efficiency within department.

Duties & Responsibilities

• Identifies opportunities to improve patient care, health care     practice and interaction with health care partners; and initiates and/or participates in development of action plans to achieve desired outcomes.
  • a. Works closely with other healthcare leaders to establish department quality indicators and to implement measures to achieve goals.
  • b. Investigates abnormal patterns of resource utilization discovered through data and outcome variances and leads improvement teams.
  • c. Serves as change agent and role model to assist LMC in attaining established goals/outcomes.
• Communicates effectively throughout the health care system.
  • a. Educates physicians and other healthcare team members regarding denials, LOS trends, etc.
  • b. Directs the preparation and maintenance of departmental reports.
  • c. Assists as needed with preparing reports to senior management, medical staff, board of directors and various committees.
  • d. Keeps AVP and health care team members informed of current activities.
  • e. Maintains efficient flow of communication throughout services by keeping staff informed of organizational issues. 
• Will embody those behaviors, philosophy, and values which serve to uphold the ideals and enhance the image of Lexington Medical Center.
  • a. Participates in hospital/medical staff committees and promotes performance improvement initiatives.
  • b. Shares knowledge with others and promotes growth and development of others
  • c. Attends and serves on professional/civic service organizations as hospital representative.    
  • d. Responsible for own professional growth and development (minimum 50 hours educational credits annually) to keep abreast of best practices for utilization management.
  • e. Networks with other community providers to assure positive working relationships. 
  • f. Serves as a professional role model for other staff.
  • g. Serves as patient advocate.
• Perform all other duties as assigned by authorized personnel or as required in an emergency (e.g., fire or disaster).