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Senior Director, Utilization Review

Job ID: 2403019830-1 Date posted: 06/10/2024 Facility: Other Executive
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Job Details

JOB DESCRIPTION:

Under the direction of the VP of Case Management & Continuing Care, the Sr. Director of Utilization Review (UR) is responsible for overseeing the development, implementation, and performance management of Utilization Review services performed across the Tenet enterprise. Leads Tenet Hospital case management operations to develop and implement centralized utilization review and authorization management services by market or region to promote an appropriate level of care and prevent payer denials. Develops structure and processes to optimize staffing and productivity. Leads evaluation and implementation of tools to leverage technology to enable program accuracy and effectiveness. Serves as the Tenet leads with Tenet National Director Clinical Denials, Sr. Director Revenue Cycle, hospital CFOs, Directors Revenue Analysis (DRAs), and Managed Care Contracting to design concurrent processes to secure authorizations and prevent clinical denials. Serves as a member of the Case Management and Continuing Care leadership team to improve Tenet hospital patient care performance as measured by key indicators including level of care, length of stay, patient throughput and compliance metrics. Directly reporting to this position are the market or regional centralized UR Team Manager and/or Director positions.

Leads continuous improvement initiatives and best practice strategies across all Tenet and USPI hospitals to achieve organizational goals through standardized systems and processes.This position will partner with the market and hospital Administrative leaders to ensure the strategies are executed at the local level. He/She will work directly with Tenet, Conifer, and USPI leaders to develop market strategies and tactics that align with company goals. This leadership position builds strong performance-based relationships, manages through roadblocks and barriers to success, and builds processes and protocols to ensure the continued sustainability of initiatives and business processes

Key focus areas:

  1. Lead Tenet Utilization Review Teams market structure and operations management to effectively support utilization review and authorization confirmation functions to promote an appropriate level of care and prevent payer denials. Completes current state assessment to define current spend and determine leading practices for system standards and local market programs needed. Develop proposal(s) and secure approval for business cases to support a comprehensive Tenet program to prevent payer denials. Works with group and market hospital leaders to develop and implement centralized utilization review and authorization confirmation teams and processes to support hospital revenue cycle processes. Works with labor management and human resources leaders to implement within Tenet standards for represented staff optimizing skill mix and productivity.
  2. Lead implementation of new technology to support utilization review processes. Serves as Tenet leader responsible to lead new technologies for automating work processes and leveraging artificial intelligence to manage UR processes by exception. This includes leading successful implementation of new systems as well as evaluating results and deploying enterprise wide where it makes sense. Supports business case and secures approval for new technologies needed to achieve organizational goals.
  3. Manages Case Management operations with Conifer teams to align and optimize case management processes related to utilization review services. Collaborates with Conifer Patient Access and appeals team leaders to monitor and manage key performance indicators to drive performance improvement and optimize workflow. Leads collaborative analysis to identify and address root cause to improve performance and achieve organizational goals.
  4. Lead successful payer authorization performance improvement for Tenet and USPI hospitals.Monitors and manages hospital performance to targets and leads corrective action plans needed to achieve organizational targets. Provides leadership to address local barriers and gaps in utilization review and authorization confirmation services. Provides hospitals with performance data analytics to make decisions and drive improvement Works with hospital and market leaders to identify when improvement plan is needed and follows up to ensure successful execution. Work directly with USPI leadership to ensure standardization in process and monitoring.
  5. Works with National Director Clinical Denials and Managed Care Contracting to identify and manage Payer Portal and address payer issues. Collects and collates data from hospitals on payer issues. Provides Tenet managed care leadership team with data to address issues with payers including avoidable days, contract violations, and process issues. Provides input to contract language to support Tenet case management services needs. Serves as advisor for Payer Portal content and payer access. Makes approval or denial decision for payer access to case management systems.
  6. Provide operations oversight to the market Central Utilization Review Team Managers and/or Directors as well as Dedicated UR sites local leadership. Supports the business planning and growth for utilization review services to support Tenet enterprise. Provides operations oversight to align processes across all Case Management and Care Continuity programs to support business growth, revenue cycle, regulatory compliance and quality care across all sites and settings of care.

Uses lean tools to address performance barriers. Develops and implements best practices to achieve organizational goals through effectively leading and managing change in a matrix environment. Oversees the implementation of action plans and monitors progress toward goals assisting with addressing barriers and challenges and making adjustments as needed in a supportive, synergistic manner. Collaborates with medical and nursing leadership, as well as case management and continuing care team members to develop and implement methods to optimize use of hospital and post-acute services.

Manages multi-disciplinary process improvement by utilizing excellent communication and servant leadership skills to challenge status quo and positively influence administrative teams and physicians to change processes to improve performance. May assist with the designing of and providing input needed for implementation and optimization of documentation systems (Cerner, PBAR, CarePort, MIDAS, etc.) to promote data integration, improve workflow and achieve key performance indicators. Fosters an environment that promotes team member support, partnership, growth and development by assessing the needs of the team and implementing programs to meet those needs. Provides analysis and education regarding regulatory and clinical changes impacting inpatient and post-acute care processes and reimbursement. Provides education and tools for educating physicians and staff regarding programs and processes. Works in alignment with hospital and Conifer leadership teams and consistently demonstrates ability to:

  • Conduct financial analysis, develop business plans and secure approval for programs
  • Develop strategies to manage and prevent disputes and Utilization Review processes with Group Directors of Case Management (DCMs) and Revenue Cycle Directors
  • Build collaborative partnerships and lead cross functional teams to execute on plans and proposals
  • Identify process inefficiencies via root cause analysis and design workflow to address opportunities identified
  • Develop and implement action plans managing follow up to achieve outcomes
  • Implement targeted process changes including ongoing metric monitoring and management to achieve goals and drive improvement

REQUIRED SKILLS:

  • A minimum of 4 years hospital or health care leadership experience required.
  • Multi-site leadership experience preferred.
  • Experience successfully implementing centralized Utilization Review teams for multi-hospital system strongly preferred.
  • Working knowledge of CarePort and MIDAS documentation and reporting required.
  • Project Management and Business Planning experience.
  • Strong analytical skills including use of Tableau and Excel; executive communication and presentation skills including ability to use PowerPoint.
Education/Certifications
  • Advanced degree in Business, Nursing and/or Health Care Administration required.
  • InterQual Certified Instruction (IQCI), Accredited Case Manager (ACM) or Certified Public Accountant (CPA) preferred, Six Sigma Green Belt preferred.
  • Valid Registered Nurse (RN) preferred
Compensation
  • Pay: $168,480 - $269,152 annually. Compensation depends on location, qualifications, and experience.
  • Position may be eligible for an Annual Incentive Plan bonus of 10%-25% depending on role level.
  • Management level positions may be eligible for sign-on and relocation bonuses.

Benefits

The following benefits are available, subject to employment status:

  • Medical, dental, vision, disability, life, AD&D and business travel insurance
  • Manager Time Off – 20 days per year
  • Discretionary 401k with up to 6% employer match
  • 10 paid holidays per year
  • Health savings accounts, healthcare & dependent flexible spending accounts
  • Employee Assistance program, Employee discount program
  • Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance.
  • For Colorado employees, paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.
Travel

Up to 50% travel.

Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.

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2403019830

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Tenet participates in the E-Verify program. Follow the link below for additional information.

E-Verify: http://www.uscis.gov/e-verify

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