Senior Director, Utilization Review

JOB DESCRIPTION:

Under the direction of the VP of Case Management & Continuing Care, the Sr. Director of Utilization Review (UR) is responsible for overseeing the development, implementation, and performance management of Utilization Review services performed across the Tenet enterprise. Leads Tenet Hospital case management operations to develop and implement centralized utilization review and authorization management services by market or region to promote an appropriate level of care and prevent payer denials. Develops structure and processes to optimize staffing and productivity.  Leads evaluation and implementation of tools to leverage technology to enable program accuracy and effectiveness. Serves as the Tenet leads with Tenet National Director Clinical Denials, Sr. Director Revenue Cycle, hospital CFOs, Directors Revenue Analysis (DRAs), and Managed Care Contracting to design concurrent processes to secure authorizations and prevent clinical denials. Serves as a member of the Case Management and Continuing Care leadership team to improve Tenet hospital patient care performance as measured by key indicators including level of care, length of stay, patient throughput and compliance metrics. Directly reporting to this position are the market or regional centralized UR Team Manager and/or Director positions.

Leads continuous improvement initiatives and best practice strategies across all Tenet and USPI hospitals to achieve organizational goals through standardized systems and processes.  This position will partner with the market and hospital Administrative leaders to ensure the strategies are executed at the local level. He/She will work directly with Tenet, Conifer, and USPI leaders to develop market strategies and tactics that align with company goals.  This leadership position builds strong performance-based relationships, manages through roadblocks and barriers to success, and builds processes and protocols to ensure the continued sustainability of initiatives and business processes

Key focus areas:

1. Lead Tenet Utilization Review Teams market structure and operations management to effectively support utilization review and authorization confirmation functions to promote an appropriate level of care and prevent payer denials. Completes current state assessment to define current spend and determine leading practices for system standards and local market programs needed.  Develop proposal(s) and secure approval for business cases to support a comprehensive Tenet program to prevent payer denials. Works with group and market hospital leaders to develop and implement centralized utilization review and authorization confirmation teams and processes to support hospital revenue cycle processes.  Works with labor management and human resources leaders to implement within Tenet standards for represented staff optimizing skill mix and productivity. 
2. Lead implementation of new technology to support utilization review processes.  Serves as Tenet leader responsible to lead new technologies for automating work processes and leveraging artificial intelligence to manage UR processes by exception.  This includes leading successful implementation of new systems as well as evaluating results and deploying enterprise wide where it makes sense. Supports business case and secures approval for new technologies needed to achieve organizational goals.
3. Manages Case Management operations with Conifer teams to align and optimize case management processes related to utilization review services.  Collaborates with Conifer Patient Access and appeals team leaders to monitor and manage key performance indicators to drive performance improvement and optimize workflow.  Leads collaborative analysis to identify and address root cause to improve performance and achieve organizational goals.
4. Lead successful payer authorization performance improvement for Tenet and USPI hospitals.  Monitors and manages hospital performance to targets and leads corrective action plans needed to achieve organizational targets.  Provides leadership to address local barriers and gaps in utilization review and authorization confirmation services.  Provides hospitals with performance data analytics to make decisions and drive improvement Works with hospital and market leaders to identify when improvement plan is needed and follows up to ensure successful execution. Work directly with USPI leadership to ensure standardization in process and monitoring.
5. Works with National Director Clinical Denials and Managed Care Contracting to identify and manage Payer Portal and address payer issues.  Collects and collates data from hospitals on payer issues.  Provides Tenet managed care leadership team with data to address iss