The Director, Utilization Management - Inpatient is responsible for providing oversight to the inpatient utilization department, and coordinating projects in concert with other departments to meet overall project goals while maintaining expertise and oversight with compliance to regulatory and accrediting requirements that are applicable to Utilization Management, and is responsible for reviewing and identifying and implanting processes to impact cost and utilization trends. Additionally, the Director will assume responsibility for all medical innovations projects and will plan, coordinate, and direct, from ideation to inception, all ideas and activities that may impact cost and care. The success of this position requires the ability to foster communication and teamwork to ensure an excellent customer experience.
Oversees the development of the departmental strategic and tactical plans. Directs the development of Utilization Management goals, objectives, policies and priorities and promotes culture of compliance to policy and procedure. Participates in the development of new policies and procedures annual review of policies and procedures.
Develops and implements processes to ensure excellence in Utilization Management. • Ensure that staff receive appropriate orientation, training and education. • Leads the team to the fulfillment of the clinical, business and service level expectations of the organization. • Provides oversight in to the development, implementation and evaluation of departmental goals and objectives.
Serves on applicable internal and external committees and actively participate in Departmental, Corporate and Network activities and projects that improve the departments performance and outcomes and assures the integration of Health Management activities within and between teams as well as across the entire Medical Department and the organization.
Maintains expertise in reimbursement methods and contract language related to Health Management activities(i.e.; DRGs, etc) and in all operational areas of the Health Management Department. • Seeks and reviews new information as it becomes available. • Ensures that the appropriate staff members are educated as needed. • Ensures that documents, policies and procedures, and workflows are up to date as needed.
Oversees all activities of Utilization area and collaborates with all business units as required. • Ensures that the team confers with the Medical Directors for cases that do not meet criteria. • Ensures that the established goal for turnaround times is monitored and takes action as needed, as well as all other compliance and SLA issues • Ensures that processes are well-defined, documented and in accordance with regulatory and accrediting agencies.
Participates in review ,selection, upgrades and training of new technology for use in the Utilization Management area. In conjunction with Medical Operations and other leadership, identifies new of enhanced technology that will improve accuracy and efficiency. Oversees the development of a standard business case and ROI documents as needed.
Provides regulatory and accrediting oversight by reviewing changes in requirements and standards and identifies gaps and opportunity. Oversees the monitoring (in the form of quality assurance activities) and enforcement of compliance with internal and external regulatory and accrediting requirement. • Identifies compliance issues. • Participates in (or designates) development/revision of policies and procedures/workflows pertaining to compliance. • Participates in (or designates) in staff education related to compliance.
Required Bachelor's Degree or equivalent in health related field
7 years of relevant experience Leadership - Required
3 years of relevant experience Managed Care experience - Preferred
3 years of relevant experience Knowledgeable of compliance and regulations as it relates to Utilization - Preferred
LIC-Registered Nurse (RN) - STATE_MI State of Michigan
LIC-Master Social Worker (MSW-Master) - STATE_MI State of Michigan
Internal Number: R9535
About Priority Health
Spectrum Health is a not-for-profit, award winning, integrated health system based in West Michigan. Our organization includes a medical center, regional community hospitals, a dedicated children's hospital, a multispecialty medical group and a nationally recognized health plan, Priority Health. We invest in our people by supporting a dynamic, high-performing workplace. Our collaborative approach to patient care includes a commitment to provide an exceptional experience for patients and their families. Spectrum Health supports successful career growth in an innovative environment.