AVP Utilization Management (RN) – Relocation Offered! Position Available In Richland, South Carolina

Job Description:

General Summary of PositionThe Assistant Vice President ofUtilization Management is responsible for hospital utilizationreview services across MedStar Health enterprise

• includesstrategic oversight, program development, staff oversight andperformance management, subject matter expertise, metricdevelopment, implementation,& mitigation actions.

Responsible forthe overall planning, direction, and implementation of roles,standardized processes, and programs for the Utilization Managementteam to ensure medically appropriate and cost-effective care.

Collaborates and partners with physicians, case management, andhospital leadership, finance, compliance, population health, andother pertinent stakeholders/ committees to ensure an alignedapproach to patient care with providing efficient, quality care,discharge planning, and utilization review Primary Duties and Responsibilities Provides strategic leadership and develops and implementsshort-and long-term strategies, policies, and best practices forthe Utilization Review Program across MedStar Health with anemphasis on a data-driven approach Oversees and implements daily utilization review RN assignmentsand caseloads. Serves as a subject matter expert for escalationsfrom Utilization Review and Appeals RNs, Physician Advisors,medical staff, revenue cycle and case management leaders. Operational oversight and implementation of standardizedutilization review practices for medical necessity reviews,secondary reviews, peer to peer discussion with payors, pre billdenial interventions in collaboration with UR/CM/RCM and medicalstaff, denial root cause determination and upstream processimprovement In collaboration with system ACM leaders and other keystakeholders, provides strategic direction and implementation ofLOS and complex discharge management initiatives and bestpractices. Identify and address clinical over or underutilizationtrends, issues/barriers to discharge, delays in service, withspecific clinical departments or other hospital-basedprocesses Provides direct consultation and education for the ACM team,medical staff and other key collaborators on regulatoryrequirements, appropriate utilization of hospital services, medicalnecessity documentation, denial management practices, and thegoals/processes of MedStar Health’s Acute Case Management andPhysician Advisor Programs Provides strategic & operational leadership to the optimizationof the ACM platform in Cerner and emerging technologies to enhancereal-time decision making, reduce administrative burden, andimprove utilization review efficiency. Promote hospital adherence to ensure compliance with CMSpolicies and updates regarding inpatient admissions, IPO list,observation status, as well as the appropriateness of continuedhospital stay. Maintains a working knowledge of criteria andcoverage guidelines used in UM process, including Federal and Stateregulations Encourages a collaborative approach to patient care with thegoal of providing efficient, quality care, discharge planning, andutilization review Collaborative approach to developing and implementing metricsat the department and individual level to drive and assessperformance of the Utilization Review Programs. Oversight andmanagement of utilization review RN staffing schedules, workloaddistribution, and RN performance. Responsible for system coordination, management, and success ofMedStar Health’s Utilization Management program across the UMcontinuum in accordance with the mission and strategic goals of theorganization, federal and state law and regulations, payerrequirements, and accreditation standards. Plans for and respondsto regulatory changes and audit activities to reduce financial riskand improve revenue recovery. Educates and partners with physician and nursing leadership,finance, compliance, and population health, and other pertinentstakeholders/committees

• Minimum Qualifications Education Master’s degree In Nursing (MSN), Healthcare Administration,Business Administration or related field required Experience 10+ years Progressive leadership experience in healthcareadministration required and 5-7 years progressive leadership experience in utilizationreview and appeals at health system level managing multiplehospitals Demonstrated record of accomplishment in health care administrationor clinical practice, and innovative practice delivery Experience with MCG and Interqual criteria required Licenses and Certifications RN•Registered Nurse•State Licensure and/or Compact StateLicensure In state of Maryland or District of Columbia Upon Hirerequired Knowledge, Skills, and Abilities Excellent communication and presentation skills, stronginterpersonal skills.

Leadership skills and demonstrates ability tolead teams and work effectively in a team, matrixedenvironment. Demonstrated ability to develop and implement strategicinitiatives. Proven ability to influence others, manage, and resolveconflict, and collaborate effectively as necessary to executegoals. Independently solves complex problems related to utilizationmanagement, human resource issues, payer and managed care, and carecoordination. Extensive knowledge of management principles, includingbudgeting, human resource planning, and other operationaltechniques required to run a large clinical enterprise. Improvement mind-set focused on driving change using actionabledata & lead change This position has a hiring range of $181,600

• $245,600

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