System Manager, Utilization Management
Job Number: 1092217
Piedmont Healthcare Corporate - Atlanta, Georgia
Shift/Schedule: Full-time
Description
System level matrix over site of the utilization management activities
KEY RESPONSIBILITIES:
1. Provides vision and direction to PHC system and entity level leadership for Utilization Management (UM)
Collaborates with EPIC team and Revenue Cycle to create reports and dashboards using supportive data to review UM activities, payer activities and financial outcomes.
Provides analysis, guidance and feedback to leadership concerning payer expectations using supportive data.
Provides guidance and feedback to leadership regarding organizational UR performance.
With leadership input, establishes goals, objectives, action plans, and monitors change management.
Assists with development and revision of UM related job descriptions.
Develops with leadership input, PHC policies and procedures for optimal UM practices.
Provides consultation in areas of expertise and communicates current payer trends, concepts and issues related to strengthening UM services across the continuum.
2. Develops and manages programs that will enhance Utilization Management
Collaborates with key physicians and other health care disciplines in developing and implementing fiscally responsible strategies.
Confers with entity level CFOs, CMOs and Case Management Directors on a regular basis to ensure consistency, effectiveness of UM activities.
Monitors all commercial and governmental denials patterns and develops concurrent denial management strategies to reduce denials
3. Utilization Management Quality Assurance
Liaison to Revenue Cycle Committee, Compliance Department, HIM, PASU, Medical Executive Committees, all commercial care payers, Managed Care Contracting, Quality Department, CFOs, CMOs and UR Physician Advisors.
Liaison to the QIO for PHC system level issues
Creates system wide infrastructure to monitor the quality of Utilization Review activities
Standardizes Utilization Management Committee Activities across the system
Stays current with all government payer UR and billing guidelines
Stays current in all commercial payer UR and billing guidelines
KNOWLEDGE, SKILLS, ABILITIES
Skill and ability to communicate effectively both verbally and in-writing.
Skill and ability to handle multiple priorities and deadlines.
Ability to work as a member of a team.
#GD
#LI-POST
#IND000
Requirements
MINIMUM EDUCATION REQUIRED:
Graduation from a School of Nursing
MINIMUM EXPERIENCE REQUIRED:
At least 5 years of experience with acute hospital utilization management and review processes, using medical necessity criteria (InterQual and/or Milliman). At least 2 years of management experience of professional staff.
MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
Current Georgia RN licensure
ADDITIONAL QUALIFICATIONS:
IQCI certification required. Detailed knowledgeable of federal and state hospital Utilization Review (UR) regulations, Medicare Conditions of Participation, Medicare Guidelines regarding medical necessity, hospital admissions processes, level of care determination, hospital services and hospital continued stays. Expert knowledge of Interqual criteria. Ability to verbally and in writing communicate with many different departments and physicians including but not limited to: Admissions Department, Patient Financial Services, Compliance, Medical Records, Physician Advisors, UR front line staff and Physician Leadership.
Diversity & Inclusion
At Piedmont Healthcare we embrace diverse ideas, perspectives, and skills to create a collaborative workplace where the best talent wants to succeed. We celebrate differences and recognize that they allow us to care for our community.
Excellence at Work
Piedmont is a certified Great Place to Work™-- a national designation based on employee feedback about trust, workplace culture and experience. In 2019, Forbes named Piedmont one of Georgia’s 10 best employers and the highest-ranked healthcare provider.