Director of Utilization Management

Roanoke, VA, US, 24014

Job Summary

Oversees the Carilion Clinic Utilization Management (UM) daily and long term operational services.  Coordinates departmental functions with hospital service lines to ensure adherence to Federal, State and payor rules and regulations regarding utilization management policy and procedures. Provides internal and external leadership for the UM team focusing efforts on utilization review, denials management, and compliance regarding all UM processes and regulatory requirements.  Communicates, organizes, prioritizes, coaches, and problem solves with all members of the UM team to ensure appropriate and accurate documentation that results in support for appropriate placement and reimbursement for the level of services rendered for all patients. Represents the Utilization Management department throughout the facility as requested. Accountable for achieving established measurable clinical and financial outcomes through active engagement of stakeholders across the continuum of care, leveraging existing and future Carilion Clinic systems, operations, business unit and service lines to support a systems- based strategy.

 

Establishes, implements, and evaluates departmental quality, service and productivity against benchmarks and scorecard measures which support Carilion Clinic and its strategic quality and process improvement initiatives.  Establishes scorecard measures and operating plans for the UM function in collaboration with the CM Senior Director. Contributes to the development of business and implementation plans with specific goals, objectives and timelines as part of the Case Management leadership team.  Identifies clinical and financial outcome opportunities for improvement through analysis of systems data.  Utilizes data systems and resources to monitor process improvement and resource utilization, Utilizes quality methodology in process improvement activities.

 

Manages all utilization review and denial and appeals staff. Ensures standards for staff qualifications, competency and continuing education. Establishes and reviews staffing plans to ensure effective resource utilization.  Responsible for performance management and improvement.   Ensures the completion of appropriate training regarding regulatory requirements and in support of improved functionality.  Participates in the management team for the CM department and assists the team as directed by the Care Management Senior Director.

 

Twenty-four hour accountability for human resource management, operational management, financial management and delivery of UM services.  Supervises Carilion Medical Center UM staff. May provide management support for other areas within Care Management Services as determined by Director. Communicates daily with staff, patients, families, physicians, other Carilion services, external customers/vendors, and the public to ensure provision of quality UM services.  Accountable for maintaining confidentiality of patient and organizational information. Ability to drive/travel between various locations is required for this position.

Minimum Qualifications

Education:  Bachelors Degree in Nursing required. Masters Degree and/or certification preferred.

Experience:  Three years of management experience that demonstrates increased and/or diversified responsibility including responsibility for managing clinical and financial outcomes and utilization management for a hospital or payor. Must possess knowledge of UM functionality and accountability. Demonstrates knowledge of State and Federal rules and regulations that drive the UM process and scope of practice.

Licensure:  Registered Nurse required.  Must be licensed to practice as a RN in the State of Virginia or compact state.  

Other Minimum Qualifications:  Ability to problem solve and to communicate effectively.  Demonstrated effective leadership, training, and usage of interpersonal skills to manage a team of clinicians through change.   Strong oral and written communication skills. Basic computer skills, knowledge of EPIC, Interqual, E-Discharge and Servo Formal training in utilization review criteria/processes highly desirable.

Our Values

Below are our core values that we strive to embody and expect of all our team members:

CommUNITY:  Working in unison to serve our community, our Carilion family and our loved ones.
 

Courage:  Doing what’s right for our patients without question.
 

Commitment:  Unwavering in our quest for exceptional quality and service.
 

Compassion:  Putting heart into everything we do.
 

Curiosity:  Fostering creativity and innovation in our pursuit of excellence.

 


Requisition Number: 27436 
Employment Status: Full time 
Location: CRMH - Carilion Roanoke Memorial Hospital 
Shift: Day 
Shift Details: Prim. Monday - Friday w/ 24 hour accountability
Recruiter: DANA E JOHNSON 
Recruiter Phone: 540-983-4006 
Recruiter Email: dejohnson@carilionclinic.org


This is Carilion Clinic ...

An organization where innovation happens, collaboration is expected and ideas are valued. A not-for-profit, mission-driven health system built on progress and partnerships. A courageous team that is always learning, never discouraged and forever curious.

Headquartered in Roanoke, Va., you will find a robust system of award winning
hospitals, Level 1 and 3 trauma centers, Level 3 NICU, Institute of Orthopedics and Neurosciences, multi-specialty physician practices, and The Virginia Tech Carilion School of Medicine and Research Institute.

Carilion is where you can make your own path, make new discoveries and, most importantly, make a difference. Here, in a place where the air is clean, people are kind and life is good. Make your tomorrow with us.

Equal Opportunity Employer

Minorities/Females/Protected Veterans/Individuals with Disabilities/Sexual Orientation/Gender Identity

Carilion Clinic is a drug-free workplace.


Nearest Major Market: Roanoke

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