Director of Utilization Management & Transitions of Care

Director of Utilization Management & Transitions of Care Family Choice of New York - 2.9 Depew, NY Job Details Full-time $95,000 - $105,000 a year 1 day ago Benefits Health savings account Health insurance Dental insurance 401(k) Flexible spending account Paid time off Employee assistance program 401(k) matching Life insurance Qualifications Optimizing workflow processes CPR Certification Long-term care regulations Operations management RN License Managed care organization experience Team leadership BLS Certification CMS Working with geriatric patients Employee relationship building Team development CMS regulatory compliance Driver's License Policy & process development Bachelor's degree Medicare regulations Geriatrics Senior leadership Post-acute care experience Full Job Description This position has overall accountability to act as an internal consultant to the operations staff in the functioning of the utilization management program. It is responsible for monitoring acute utilization, training UM staff in the principles of utilization management, preparation of accurate utilization management reports, and timely and accurate submission of utilization management data. In addition, the position will serve as back up to the RN Coordinators.

TASKS:

Oversee and manage utilization management, in accordance with CMS requirements, FCNY, and IHA policies and procedures. This includes Part A utilization in the acute and post-acute SNF setting, including admission, on-going certification of medical necessity, and discharge when medical necessity needs are no longer met. Responsible for overseeing the concurrent review of Medicare Part A and SAR stay length of stay. Oversee and manage the provision of the Part A TIP Services Program in compliance with facility contracts and CMS compliant Part A utilization. Oversee FCNY Early Care Program in compliance with facility contracts. Lead UM and transitions process improvement initiatives and identify opportunities to optimize processes that drive positive outcomes. Assure that Utilization Management department follows applicable policies and procedures. Attend monthly UM/QM meetings. Review data to detect outliers, trends, and unusual patterns of utilization and recommend interventions to the UM committee and management team. Monitor service delivery and outcomes to ensure services are not over-utilized or under-utilized. Participate and attend operational and clinical meetings as directed. Participate and lead provider and facility training on UM processes, levels of service/criteria, and IHA billing scenarios Monitors partner facility adherence with quality indicators and model of care requirements. Advise health plan of prolonged or clinically intensive hospitalizations per policy. Manage and oversee Transitional Care Management across all SNP programs. May actively communicate with network partners regarding transitions. Oversee and monitor reconciliation of wrapped transitions. May assist and oversee diversions in both SNP Programs. Oversight of Transitions of Care for SNP Members in

EHR or Care Management Record:

Inpatient, ER, Observation, and all planned and unplanned transitions. May prepare quality review of transitions of care as requested by management. May identify trends and areas for improvement within partnering facilities as requested by the Director of Quality and Compliance or Director of ISNP and Clinical Services. May conduct informal facility staff education and teaching to improve the effectiveness and efficiency of care delivery. Provide back up to department team members as needed. Performs quality reviews on all record requests. Other duties as assigned.

MANAGEMENT RESPONSIBILITIES

Determine staffing requirements. Recruit, hire and onboard/train new staff. Supervise direct reporting staff according to overall company policy. Set employee goals and objectives. Monitor and conduct performance evaluations of staff at the end of the 90-day introductory period, at established development plan dates and at annual anniversary dates for own direct reports. Delegate work duties to staff to attain objectives. Provide coaching, disciplinary/corrective action as necessary up to termination. Develop staff to maximize potential. Develop department procedures. Apply strategic planning to determine company, department or unit objectives. Collaborate with and contribute to the Leadership Team. Other duties as assigned.

EDUCATION

Registered Nurse licensed in the State of New York, Bachelor's degree preferred

EXPERIENCE/ABILITIES

Minimum of 5 years of experience with geriatric population. Knowledge of CMS, NCQA, and URAC standards and regulations related to quality and utilization management, physician networks, and other managed care organizations. At least 3 years of demonstrated leadership and management in a senior role with a health care organization specializing in the care of geriatric patients. Must be able to build and maintain collaborative, cooperative, productive relationships with all internal and external customers including members and their families nursing facility staff, physicians, the health plan and any other stake holders in the community. Must be goal oriented with a strong sense of personal initiative and accountability to achieve performance targets. Experience in the development and execution of processes to improve workflow, efficiency, and effectiveness.

REQUIREMENTS

CPR certification Valid NYS Driver's License and maintain automobile insurance per company requirements All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity or expression, age, or national origin.

Job Type:

Full-time Pay:

$95,000.00 - $105,000.00 per year

Benefits:

401(k) 401(k) matching Dental insurance Employee assistance program Flexible spending account Health insurance Health savings account Life insurance Paid time off

Work Location:

In person