Director-Utilization and Denials Management

Location: WellSpan Health, York, PA

Schedule: Full Time

General Summary

Supervises and oversees the operations of the utilization management department. Works with hospital, regional, medical group, Population Health, post-acute services, revenue services and system leadership to support the operational achievement of strategic goals and in the innovation, design, and implementation of new strategies to continue to improve operations and clinical services. Collaborates with interdisciplinary teams, such as Insurance Specialty Center, Payor Contracting, Compliance, IT, Finance, and Regulatory Affairs to enhance WellSpan Health's utilization management capabilities and execution through the development of strong management relationships. Provides leadership regarding future strategic goals and the integration of utilization management principles throughout the System.

Duties and Responsibilities

• Oversees the utilization management process for preauthorization, concurrent review, denials and appeals for System acute care facilities.

• Directs, coordinates, and evaluates efficiency and productivity of utilization management functions.

• Leads strategic goals and priorities across utilization management that support WellSpan's strategic priorities and objectives.

• Develop, review, implement and oversee effective administration of Utilization Management workflow and processes in accordance with contract compliance as well as regulatory requirements.

• Oversees and evaluates the activities and effectiveness of Utilization Management activities.

• Build a high-functioning team that meets all operating goals, including quality, efficacy, administrative expense, customer service, performance improvement, regulatory requirement satisfaction, and staff engagement.

• Provide oversight of utilization management, denials and Prior Authorization activities to ensure utilization review activities are conducted timely in accordance with internal policy and payor requirements.

• Monitor operations and implement strategies that promote compliance with regulatory standards.

• Provide mentoring and coaching to direct reports to build and strengthen Utilization Management effectiveness.

• Ensure regular departmental staff meetings are conducted and action items and follow-up issues are completed.

• Partner with other Departments to develop, implement, and monitor system-wide performance improvement initiatives for Utilization Management measures.

• Coordinate with other operational departments to identify and achieve workflow improvements to gain process and procedure efficiencies and create standardized reporting across all functional areas.

• Identify, design and implement Process Improvement opportunities that support utilization management operations.

• Participates as a member of Utilization Management Review Committees. Co-chair's System Utilization Management Committee.

• Works closely with Medical Director to identify trends in payor denials and appeals.

• Serves as point of contact for System acute care utilization review issues and resolutions with payers. Collaborates with Payer Contracting regarding payer issues. Attends Joint Operations Committee Meetings with payers.

• Organizes and assists Medical Director with System Utilization Management Committee (URC) meetings. Prepares reports for review at the URC meeting.

• Works with medical and professional staff on a case-by-case basis to obtain appropriate clinical documentation for review as well as coding activities and DRG assignments.

Common Expectations:

• Oversees the hiring and performance of the support staff for case management across System entities by assisting in selecting staff, training/orientation of personnel, evaluating performance, preparing work schedules, and making recommendations for personnel actions.

• Develops budget(s) for the department/unit/entity and allocates funds within budget(s) to accomplish objectives. Monitors variance against budget(s) Maintains established policies and procedures, objectives, quality assessment and safety standards.

• Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.

• Attends meetings as required.

• Prepares and presents utilization data analysis as required.

Qualifications

Minimum Education:

• Masters Degree Required

Work Experience:

• 5 years In leadership experience. Required

• 3 years Utilization Management Experience. Preferred

Licenses:

• Licensed Registered Nurse Preferred

Knowledge, Skills, and Abilities:

• Advanced computer skills, including database management, EXCEL.

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At WellSpan Health, we are committed to treating all applicants fairly and equitably, regardless of their job classification. If you require assistance or accommodation due to a disability, please reach out to us via email atcareers@wellspan.org. We will evaluate requests for accommodation on a case-by-case basis. Please note that we will only respond to inquiries related to reasonable accommodation from this email address. Rest assured, all requests for assistance or accommodation are handled confidentially, allowing applicants to share their needs openly and honestly with us.

WellSpan Health is an Equal Opportunity Employer. It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic.