Director Utilization Management
Kaleida Health, Buffalo, NY, United States
Job Description
Work flows across all sites. This includes consistent practice and issuance of admission denials, concurrent denial notices, level of care determinations, ensuring patients are afforded appeal rights and financial responsibility is appropriately assigned. Responsible for timely concurrent and retrospective medical necessity appeals and denial management for all lines of business including quarterly insurance company audits and CMS RAC /MAC determinations. Responsible for review of data, determining trends, making recommendations to Senior Financial Team, and implementing changes to meet demands. Works closely with Compliance to meet CMS, DOH & DNV regulations. Responsible for system-wide implementation of payer contracts as related to Utilization Review. Has significant quality of care and financial implications to Kaleida. Key contact for utilization review issues / concerns / and implementation of consistent policies with commercial insurance companies. Works closely with contracting for recommendations on improving utilization position within contracts. Location
Larkin Bldg @ Exchange Street (Buffalo, NY). Job Type
Full-Time, Shift 1. Education and Credentials
Bachelor's in Nursing, Healthcare, Health Care Administration or similar required. Master's in Nursing, Healthcare, Health Care Administration or similar preferred. Experience
10 years of experience in a healthcare environment required. 5 years of experience in utilization management, discharge planning. 5 years' work experience in payer/insurance HMO environment. Knowledgeable in CMS, DOH regulations, experience with regulatory audits. 5 years of experience with insurance carriers, payer policy trends & revenue cycle management concepts. 3 years of experience with Interqual software, Excel, Microsoft. 3 years of experience in a multi-hospital system required. 3 years of experience with federal, state and accreditation guidelines, financial principles, coverage issues and insurance / managed care practices. RN license required upon hire. Working Conditions
Essential: Weight requirement - sedentary (10 lbs). Job Details
Department: BGMC Utilization Review. Standard hours bi-weekly: 75.00. Weekend/holiday requirement: No. On-call required: No. Requisition ID#: 17678. Grade: EX218. Pay frequency: Bi-Weekly. Salary range: $109,414.50 - $150,442.50. Wage will be determined based on factors such as candidate's experience, qualifications, internal equity, and any applicable collective bargaining agreement. With rotation: Scheduled work hours 8a-4p. Work arrangement: Onsite. Union code: N00 - Non Union KH. Kaleida Health’s mission is to advance the health of our community, and we believe our diversity, equity, and inclusion (DEI) strategic work is mission-critical for the good of our workforce and the community who need and depend on our care and services. We understand that racism and health inequities stand firmly in the way of advancing the health of our community, and Kaleida Health envisions DEI as the pursuit of equity and restorative justice for every person. We will exemplify courage and accountability through both the professing and practice of our core values for our friends, colleagues, and community. Kaleida Health is committed to creating a culture of equity and inclusion where diversity is valued and celebrated!
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Work flows across all sites. This includes consistent practice and issuance of admission denials, concurrent denial notices, level of care determinations, ensuring patients are afforded appeal rights and financial responsibility is appropriately assigned. Responsible for timely concurrent and retrospective medical necessity appeals and denial management for all lines of business including quarterly insurance company audits and CMS RAC /MAC determinations. Responsible for review of data, determining trends, making recommendations to Senior Financial Team, and implementing changes to meet demands. Works closely with Compliance to meet CMS, DOH & DNV regulations. Responsible for system-wide implementation of payer contracts as related to Utilization Review. Has significant quality of care and financial implications to Kaleida. Key contact for utilization review issues / concerns / and implementation of consistent policies with commercial insurance companies. Works closely with contracting for recommendations on improving utilization position within contracts. Location
Larkin Bldg @ Exchange Street (Buffalo, NY). Job Type
Full-Time, Shift 1. Education and Credentials
Bachelor's in Nursing, Healthcare, Health Care Administration or similar required. Master's in Nursing, Healthcare, Health Care Administration or similar preferred. Experience
10 years of experience in a healthcare environment required. 5 years of experience in utilization management, discharge planning. 5 years' work experience in payer/insurance HMO environment. Knowledgeable in CMS, DOH regulations, experience with regulatory audits. 5 years of experience with insurance carriers, payer policy trends & revenue cycle management concepts. 3 years of experience with Interqual software, Excel, Microsoft. 3 years of experience in a multi-hospital system required. 3 years of experience with federal, state and accreditation guidelines, financial principles, coverage issues and insurance / managed care practices. RN license required upon hire. Working Conditions
Essential: Weight requirement - sedentary (10 lbs). Job Details
Department: BGMC Utilization Review. Standard hours bi-weekly: 75.00. Weekend/holiday requirement: No. On-call required: No. Requisition ID#: 17678. Grade: EX218. Pay frequency: Bi-Weekly. Salary range: $109,414.50 - $150,442.50. Wage will be determined based on factors such as candidate's experience, qualifications, internal equity, and any applicable collective bargaining agreement. With rotation: Scheduled work hours 8a-4p. Work arrangement: Onsite. Union code: N00 - Non Union KH. Kaleida Health’s mission is to advance the health of our community, and we believe our diversity, equity, and inclusion (DEI) strategic work is mission-critical for the good of our workforce and the community who need and depend on our care and services. We understand that racism and health inequities stand firmly in the way of advancing the health of our community, and Kaleida Health envisions DEI as the pursuit of equity and restorative justice for every person. We will exemplify courage and accountability through both the professing and practice of our core values for our friends, colleagues, and community. Kaleida Health is committed to creating a culture of equity and inclusion where diversity is valued and celebrated!
#J-18808-Ljbffr