Job Description
The Manager-Utilization Review and Insurance Verification reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
Responsibilities:
- Lead, plan, and coordinate the Quality Utilization programs at the business unit level, in collaboration with the System Director of Clinical Documentation and the Medical Director(s) of Quality Utilization.
- Scope includes all functions which support medical necessity documentation within the patients medical record.
- Scope includes all practitioners, clinicians and others participating in delivering or supporting patient care, including those privileged through the medical staff, trainees, students, employees, volunteers.
- In collaboration with the regional leadership, develop, implement, manage and achieve annual Quality Utilization plans, and other supporting plans.
- Collaborate in advancing the work of business unit functions, including Quality Utilization, Clinical Documentation Improvement, Coding, Quality, Compliance, and other activities across the region.
- As assigned, assume leadership in advancing these programs on a regional or system-wide level.
- Design, lead, implement, teach and monitor NM Quality Utilization practices, policies, protocols and methodologies.
- Staff and support the Quality Utilization Committee.
- Manage/oversee the subcommittees of the Quality Utilization Committee.
- Assure and support adherence to Medicares Conditions of Participation.
- Assure and support accurate, appropriate and timely billing of inpatient and outpatient observation patient hospitalizations, including concurrent denial management as needed.
- Design, lead, implement, teach and monitor use of technology and data driven approaches to adhering to government rules and regulations and commercial payer guidelines.
- Identify, develop, and implement key strategies to leverage the electronic health record (EHR) and other tools to facilitate accurate representations of medical necessity and care delivered within the medical record.
- Partner with regional leadership to identify, prioritize by clinical area, and facilitate improvements in utilization review.
- Assure and support practices to promote accuracy of publicly reported data.
- Partner with leaders from Revenue Cycle and Finance to identify, respond to and learn from post-payment denials.
- Assist with appeal activities as necessary.
- Implement surveillance and reporting to identify areas of concern and strength.
- Monitor internal and external trends to identify priorities.
- Assure and support training for the Quality Utilization Team.
- Plan and lead improvement initiatives, innovation and transformation activities.
- Recruit and develop staff, teach/orient/train, manage financial and human resources efficiently and effectively.
- Maintain high levels of staff engagement and performance.
- Collaborate effectively across the system, including but not limited to directors and managers of quality / process improvement / analytics, chief medical officers, chief nursing executives, operations executives.
- Advance the standard of quality and safe patient care across NM through innovation, learning and shared deployment of best practices.
