Director, Utilization Review (Remote based in US) & 50%+ Travel

Under the direction of the VP Case Management & Continuing Care, the National Director, Central Utilization Review (UR) is responsible to oversee the development, implementation and performance management of Utilization Review services performed across all Tenet acute hospitals.

Under the direction of the VP Case Management & Continuing Care, the National Director, Clinical Denials is responsible to oversee the development, implementation and performance management of the Tenet Clinical Denials Prevention and Appeals Management program across all Tenet acute hospitals.  Leads Tenet case management services to promote appropriate level of care and length of stay processes and documentation to prevent clinical denials. 

Serves as the Tenet lead with Tenet National Director Utilization Review (UR), Sr. Director Revenue Cycle, hospital CFOs, Directors Revenue Analysis (DRAs), Directors of Patient Access and Managed Care Contracting to identify and address root cause for denial prevention and appeals. 

Serves as Tenet lead with Conifer Sr. Director Client Delivery for Tenet case management participation with denial management and denials prevention initiatives. 

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. 

Leads continuous improvement initiatives and best practice strategies across all Tenet 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 are in alignment 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 continued sustainability of initiatives and business processes

 Key focus areas:

• Lead Tenet case management clinical denial prevention and management initiatives to support appropriate level of care.  Works closely with Conifer leaders to complete current state assessment, evaluate and implement leading practices for system standards and/or local market programs needed.  Evaluates clinical denials and appeals data, documentation and workflows to identify and address Tenet and/or Conifer process and performance gaps. 
• Manage Tenet Case Management contract with Conifer Resource Center (CRC) clinical appeals team to align and optimize case management processes related to revenue cycle, denial prevention and appeals.  Collaborates with CRC, Conifer Patient Access and Conifer leaders to monitor and manage key performance indicators to drive performance improvement and optimize workflow.  Leads collaborative analysis to identify and address root causes to improve performance and achieve organizational goals. 
• Lead successful denials prevention and performance improvement for Tenet hospitals.  Monitors and manages Tenet hospital performance to targets and leads corrective action plans needed to achieve organizational targets.  Collaborates with National Director Utilization Review 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 with National Director UR and Managed Care Contracting to identify and address payer and Independent Review Organization (IRO) issues. Collects and collates data from hospitals on payer issues and IRO results.  Provides Tenet managed care leadership team with data to address issues with payers including avoidable days, contract violations, and process issues. Provides input to contract language to support Tenet case management service needs.  Participates with Tenet Appeals Physician Advisor in identifying and addressing trends with payer medical directors.
• Provide oversight for Conifer processes related to Tenet Appeals Physician Advisor (PA) and potential account downgrades.  Supports the development and implementation of clinical appeals workflow to incorporate Tenet Appeals PA review prior to any account downgrade.  Works with Conifer and Tenet Appeals PA to identify opportunities for improvement including documentation and process.  Utilizes findings for process improvement and hospital PA and case management education.  Identifies trends to address with managed care contracting and plan medical directors.
• Uses lean tools to address performance barriers.  Develops and implements