Director, Utilization Management
Job ID: R0042044 | Finance Leadership | Full Time | Charlottesville, VA
The Director of Utilization Management (UM) is an integral member of the Revenue Cycle division, working closely with financial and clinical operations to provide strategic direction in support of operational performance and key financial metrics. The Director is responsible for oversight of the day-to-day operations of all enterprise utilization management functions, to include developing effective and efficient processes for determining the appropriate admission status based on regulatory and reimbursement requirements of various commercial and government payers.
  • Develops policies and procedures to ensure all hospitalized patients have the correct admission status (inpatient, outpatient short stay, observation status) so that the appropriate claim can be submitted to commercial and government payers at discharge.
  • Develops and maintains efficient and effective documented policies and procedures for non-coverage notifications, including Notice of Non-coverage (HINN) and Advance Beneficiary Notice of Noncoverage (ABN), to include compliance monitoring.
  • Overseea all Utilization Management functions, to include daily operations management; budget; productivity; quality; education and training; auditing; report management; performance improvement initiatives; and developing standardized practices, processes, policies, and procedures.
  • Monitors the effectiveness/outcomes of the UM program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed.
  • Collaborates with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status.
  • Monitors and analyzes the productivity and quality of utilization management operations, while providing ongoing feedback and education for the staff. Ensures compliance with regulatory requirements and application of clinical decision support criteria for utilization activities deemed by federal, state, and other regulatory and accreditation agencies. Serves as a key leader in UM workflow design and management under Epic financials.
  • Serves as Co-Chair of the Utilization Management Committee.
  • Understands interrelationships among systems and processes across functional areas to evaluate processes, improve efficiency, and ensure optimal results.
  • Actively seeks to promote and maintain a professional team-oriented, service-conscious culture that contributes to the goals of the department and organization.
  • Fosters a positive and proactive work environment, emphasizing respect for individuals, high standards of quality, customer service, innovation, and teamwork.
  • Maintains personal professional growth and development through seminars, workshops, and professional affiliations.
Position Compensation Range: $106,974.40 - $171,163.20 Annually

  • Education: Master's degree in business or related field required. Master's degree in Science Nursing preferred.  
  • Experience: Minimum five (5) years of healthcare financial management that includes revenue cycle or related experience working directly in Utilization or case management.
  • Licensure: Certified Case Manager (CCM), Certified Professional in Utilization Management (CPUM), or other applicable certification preferred.

This is primarily a sedentary job involving extensive use of desktop computers. The job does occasionally require traveling some distance to attend meetings and programs.

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Charlottesville, VA
Charlottesville, VA 22903

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