Director of Utilization Management and Care Coordination

CommonSpirit Health; Houston (TX); On-site; USD 72,000 - 107,000; Full time

Job summary

CommonSpirit Health in the Houston area is seeking a Director of Utilization Management to lead the market's UM program and staff within the Care Coordination model. You will oversee authorizations, inpatient reviews, denials, appeals, and ensure compliance with payer and regulatory requirements.

You will collaborate with the Division Director Care Coordination to develop strategies, monitor performance, and drive optimization of outcomes and quality metrics across the UM program at Baylor St.

Qualifications

• Bachelor's degree in Nursing, Health Care Administration or advanced clinical degree.
• Minimum 3 years of clinical case management (Utilization Management, Denial Management, Care Coordination).
• 5 years of progressively responsible management experience.
• Extensive operational experience in managed care; program planning, implementation, staff development, and needs assessment.
• Comprehensive knowledge of utilization management, financial management that includes revenue cycle, Medicare, Medicaid, and commercial admission and review requirements.

Responsibilities

• Lead development, implementation, evaluation and direction of the Utilization Management Program and staff.
• Process authorizations, inpatient admission and continued stay reviews, retrospective authorizations utilizing standardized criteria to determine medical necessity.
• Manage concurrent denials, appeals and reconsiderations with medical necessity determinations.
• Collaborate with the Division Director Care Coordination to develop strategies to meet departmental and CommonSpirit Health goals.
• Oversee UM policies, procedures and processes; accreditation activities; payer requirements compliance; outcomes and quality metrics analysis.

Education

Bachelor's degree in Nursing, Health Care Administration or advanced clinical degree

Job description

CommonSpirit Health in the Houston area is seeking a Director of Utilization Management to lead the market's UM program and staff within the Care Coordination model. You will oversee authorizations, inpatient reviews, denials, appeals, and ensure compliance with payer and regulatory requirements.

You will collaborate with the Division Director Care Coordination to develop strategies, monitor performance, and drive optimization of outcomes and quality metrics across the UM program at Baylor St.