Job Information

AdventHealth Divisional Director Utilization Management CFDS in Altamonte Springs, Florida

Description

AdventHealth Corporate

All the benefits and perks you need for you and your family:

  • Benefits from Day One

  • Career Development

  • Whole Person Wellbeing Resources

  • Mental Health Resources and Support

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: Full-time

Shift : Monday-Friday

Job Location : Virtual

The role you’ll contribute:

The Utilization Management Divisional Director reports directly to the Utilization Management Executive Director and is responsible for oversight of the strategic direction setting, management, continuous improvement, and maintenance of the division’s Utilization Management team. The Utilization Management Divisional Director works in close collaboration with the Physician Advisors, Revenue Cycle leaders, and Managed Care representatives to design and implement denial prevention strategies across the division that align with the AdventHealth mission. The Utilization Management Divisional Director will be responsible for providing support to the division, to ensure compliance and to optimize outcomes across facilities, offering both standardization and stability.

The Utilization Management Divisional Director ensures principle duties and job responsibilities are achieved through the supervision and direction of the Utilization Management Managers. The Utilization Management Divisional Director will review monthly metric reports and mitigation plans from each of their assigned facilities and provide a summary to facility and corporate leadership.

The value you’ll bring to the team:

  • Evaluates the efficiency, clinical appropriateness, and necessity of the use of medical services/procedures in the most resourceful clinical setting under the most appropriate status

  • Ensures compliance in both government and contractual guidelines

  • Communicates changes appropriately and efficiently, developing action plans as needed in collaboration with facility and divisional leadership

  • Provides support and acts as a liaison to provider relations for issues related to Utilization Management efforts

  • Maintains working knowledge of payor standards for Utilization Management functions

  • Reviews existing Utilization Management policies and recommends revisions; assists with the development and subsequent implementation of new and/or revised policies and procedures; ensures compliance with all AdventHealth policies and procedures

  • Works collaboratively with Physician Advisors to address status change, peer-to-peer, and concurrent denial opportunities

  • Remains current on denial trends and performs root cause analyses to address issues

  • Demonstrates clinical assessment knowledge and critical thinking skills to support Utilization Management inquires, denial avoidance strategies and payor/regulatory guidelines

  • Participates in Centers for Medicare and Medicaid Services (CMS) required Utilization Management Committee, managed care, finance, revenue cycle, and other committees as necessary

  • Reviews data analysis of identified metrics; develops, implements and monitors action plans when benchmarks are not met; reports findings to appropriate divisional and facility leaders

  • Collaborates with assigned divisional/facility CFOs to coordinate Utilization Management strategies/functions

  • Provides input to managed care department on Utilization Management activities and communicates current contract information to facilities

  • Works collaboratively with leaders of Care Management to quickly and efficiently address any Care Management or Utilization Management concerns or barriers

  • Directs the activities of the Utilization Management Manager(s)

  • Maintains full knowledge of inpatient care guidelines and shares with applicable Revenue Cycle departments

  • Collaborates with facility and divisional Executive Teams regarding Utilization Management

  • Informs and updates local facility and divisional CFOs on issues that impact the strategic goals and objectives of the facility

  • Represents the division in administrative meetings established to enhance the working relationship with contracted providers (IPA, Health Plans, Medical Group, etc.)

Qualifications

The expertise and experiences you’ll need to succeed:

Minimum qualifications :

  • RN, Bachelor of Science in Nursing or Healthcare related BS/BA or completion of degree within 24 months

  • 5+ years clinical experience in acute care facility

  • Strong presentation skills with the ability to engage others

  • Previous professional leadership and/or management experience

  • 5+ Current experience in utilization review

  • Previous experience with denials and appeals (minimum three years)

  • 3+years’ experience mentoring others

LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:

  • Active state specific RN

  • National Certification as Accredited Case Manager (ACM) or Certified Case Manager (CCM)

Preferred qualifications :

  • ACM, CCM, CRCR

  • MSN/MBA

  • Care Management/Transitional Care experience

  • 3-5 years of Director and/or Manager of Utilization Management level of experience

  • Previous experience with clinical denials and appeal

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

Category: Case Management

Organization: AdventHealth Corporate

Schedule: 1 - Day

Shift: AdventHealth

Req ID: 22034261

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.