Manager, Central Utilization Review- Full Time, Days, 8 AM - 4 PM, Morristown NJ

Atlantic Health; Morristown (NJ); On-site; USD 110,000 - 140,000; Full time

Job summary

Atlantic Health is seeking a Manager for Central Utilization Review in Morristown, NJ. The role leads denial prevention initiatives and collaborates with revenue cycle leaders to optimize care levels, documentation, and workflows across hospital sites.

Responsibilities include overseeing appeals with Physician Advisors, coordinating with managed care, and driving data-backed improvements in utilization review. RN leadership and case management experience are essential.

Qualifications

• Graduate of an accredited school of nursing.
• Advanced degree in Business, Nursing and/or Health Care Administration required.
• Leadership experience care and management of acute hospitalized patients.
• Case management training from a professional Case Management organization, preferred.

Responsibilities

• Lead clinical denial prevention and management initiatives to support appropriate level of care.
• Collaborates with Executive Director of Case Management to address barriers and gaps in utilization review and authorization confirmation services.
• Provide oversight for appeals assigned to the Physician Advisor (PA) and potential account downgrades.
• Works with Conifer and Tenet Appeals PA to identify opportunities for improvement including documentation and process.
• Oversees the development and implementation of clinical appeals workflow to incorporate PA review prior to any account downgrade.
• Develops and implements best practices to achieve organizational goals through leading change in a matrix environment.
• Monitors performance and drives improvement through data analytics and cross-functional collaboration.

Education

Graduate of an accredited school of nursing

Advanced degree in Business, Nursing and/or Health Care Administration

Job description

Manager, Central Utilization Review- Full Time, Days, 8 AM - 4 PM, Morristown NJ

Morristown, NJ, United States

Job Description

1. Lead AHS clinical denial prevention and management initiatives to support appropriate level of care. Works closely with AHS revenue cycle leaders to complete current state assessment, evaluate, and implement leading practices for system standards and/or local market programs needed. Evaluates clinical denials and appeals data, documentation, and workflows to identify and address process and performance gaps.
2. Lead successful denials prevention and performance improvement for AHS hospitals. Monitors and manages AHS hospital performance to targets and leads corrective action plans needed to achieve organizational targets.
3. Collaborates with Executive Director of Case Management to address barriers and gaps in utilization review and authorization confirmation services. Provides hospitals with performance data analytics to make decisions and drive improvement. Works with hospital and market leaders to identify when improvement plan is needed and follows up to ensure successful execution.
4. Work with Managed Care Contracting to identify and address payer and Independent Review Organization (IRO) issues. Collects and collates data from hospitals on payer issues and IRO results. Provides AHS managed care leadership team with data to address issues with payers including avoidable days, contract violations, and process issues. Provides input to contract language to support AHS case management service needs. Participates with AHS Appeals with Physician Advisor in identifying and addressing trends with payor medical directors.
5. Provide oversight for appeals assigned to the Physician Advisor (PA) and potential account downgrades. Supports the development and implementation of clinical appeals workflow to incorporate AHS Appeals PA review prior to any account downgrade. Works with Conifer and Tenet Appeals PA to identify opportunities for improvement including documentation and process. Utilizes findings for process improvement and hospital PA and case management education. Identifies trends to address with managed care contracting and plan medical directors.
6. Uses tools to address performance barriers. Develops and implements best practices to achieve organizational goals through effectively leading and managing change in a matrix environment. Oversees the implementation of action plans and monitors progress toward goals assisting with addressing barriers and challenges and adjusting as needed in a supportive, synergistic manner. Collaborates with medical and nursing leadership, as well as case management members to develop and implement methods to optimize use of hospital and post-acute services.
7. Manages multi-disciplinary process improvement by utilizing excellent communication and servant leadership skills to challenge status quo and positively influence administrative teams and physicians to change processes to improve performance.
8. Provides analysis and education regarding regulatory and clinical changes impacting inpatient and post-acute care processes and reimbursement. Provides education and tools for educating physicians and staff regarding programs and processes.

Works in alignment with hospital and revenue cycle leadership teams and consistently demonstrates ability to:

• Conduct financial analysis, develop business plans and secure approval for programs.
• Develop strategies to manage and prevent disputes and improve revenue cycle processes.
• Build trusting relationships with hospital and revenue leaders to successfully implement new programs.
• Build collaborative partnerships and lead cross functional teams to execute on plans and proposals.
• Identify process inefficiencies via root cause analysis and design workflow to address opportunities identified.
• Develop and implement action plans managing follow up to achieve outcomes.
• Implement targeted process changes including ongoing metric monitoring and management to achieve goals and drive improvement

Supervisory Responsibilities

The UR Nurses and Insurance specialist will report to this Central UR Manager

Qualifications

Education

• Graduate of an accredited school of nursing.
• Advanced degree in Business, Nursing and/or Health Care Administration required.

Experience

• Leadership experience care and management of acute hospitalized patients.
• Experience in acute care case management,
• Case management training from a professional Case Management organization, preferred.

Required Licenses, Certifications and/or Registrations

CertificatesACMA or CCM preferred

LicensesCurrent state license as a Registered Nurse

About Us

At Atlantic Health, our promise to our communities is; Anyone who enters one of our facilities will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 22,000 team members. Headquarters in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include:

• Atlantic Health Morristown Medical Center, Morristown, NJ
• Atlantic Health Overlook Medical Center, Summit, NJ
• Atlantic Health Newton Medical Center, Newton, NJ
• Atlantic Health Chilton Medical Center, Pompton Plains, NJ
• Atlantic Health Hackettstown Medical Center, Hackettstown, NJ
• Atlantic Health Goryeb Children's Hospital, Morristown, NJ
• Atlantic Health CentraState Healthcare System, Freehold, NJ
• Atlantic Medical Group
• Atlantic Visiting Nurse
• Atlantic Mobile Health
• Atlantic Rehabilitation

We have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group.

We have received awards and recognition forthe services we have provided to our patients, team members and communities. Below are just a few of our accolades:

• Chosen for 17years by Fortune as one of the magazine’s“100 Best Companies to Work For.