Director, Utilization Review

If you are looking to make an impact on a meaningful scale, come join us as we embrace the Power of One!
 

We strive to be an employer of choice and establish a reputation for being a talent rich organization where Associates can grow their career caring for others. For over a century, we’ve served the health care needs of the people of Memphis and the Mid-South.
 

The Director of Utilization Management is responsible for the coordination, management, and success of MLH Utilization Management (UM) program. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

 

Working at MLH means carrying the mission forward of caring for our community and impacting the lives of patients in every way through compassion, a deliberate focus on service expectations and a consistent thriving for excellence.

A Brief Overview
The Director of Utilization Management is responsible for the coordination, management, and success of MLH Utilization Management (UM) program. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

What you will do

• Responsible for the coordination, management and success of MLH’s Utilization Management (UM) program across the UM continuum from initial authorization to appeals and case adjudication.
• Collaborates with clinical staff and payors to ensure medically appropriate and cost-effective care, through the application of nationally recognized utilization criteria.
• Oversees and manages departmental operations to assure the consistent and appropriate performance of prospective, concurrent and retrospective reviews.
• Collects, analyzes and reports on data related to the utilization of medical services and resources and prioritizes performance improvement initiatives based on data analysis.
• Responsible for managing the Utilization Management team, including staff mentorship, budgeting, human resource planning, and process improvement.

Education Qualifications

• Master's Degree Nursing required
• Bachelor's Degree preferred

Experience Qualifications

• 10+ years progressive responsible experience in utilization review and appeals
• 5-7 years inpatient acute care utilization review experience
• In lieu of Master's degree, the candidate must have a Bachelor’s degree and twelve (12) years of relevant utilization review experience

Skills and Abilities

• Ability to organize and manage daily work flow and reporting responsibilities for UM team across all MLH, Le Bonheur Children's Hospital
• Ability to make judgments and influence change on a routine basis with capability of presenting clinically credible information in support of decision-making
• Strong clinical nursing experience and clinical judgment
• Goal oriented and action-focused, with the tenacity to engage cross-functionally to resolve issues
• Ability to plan, organize, direct, implement and evaluate processes
• Ability to establish new and manage long-term payor relationships
• Extensive knowledge of nationally-recognized utilization management criteria and standards
• Extensive knowledge of reimbursement practices and third party payer practice and regulations
• Knowledge and understanding of State and Federal regulatory requirements, including Tennessee-specific regulations
• Knowledge of current care practices for multiple clinical areas spanning inpatient and outpatient
• Comprehensive understanding of the denial and appeal process for all hospital departments
• Knowledge of healthcare accounts receivable management and documentation standards/ deviations
• Familiarity with payor contractual agreements and in-depth knowledge of criteria and coverage guidelines used in the utilization management process, including Federal and State regulations

Licenses and Certifications

• Registered Nurse Tennessee - Tennessee Board of Nursing required
• Accredited Case Manager - American Case Management Association required or
• Case Manager - The Commission for Case Manager Certification
• Care Guidelines Specialist – ISC/GRC Milliman Care Guidelines required

Supervision Provided by this Position

• Manages all associates in the utilization management department.

Physical Demands

• The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
• Must have good balance and coordination.
• The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
• The Associate is required to have clo