Ascension Health Regional Director- Utilization Management & Denial Avoidance in Lisle, Illinois

Job ID: 273185

Regional Director- Utilization Management & Denial Avoidance

Lisle, Illinois

Regular/Day

Additional Job Information

Title: RN Dir-Util Mgmt ACM

City, State: Lisle,IL

Department: Total Quality Management 002

Additional Job Details: Full-Time,Day, 40 hours,Weekly

About Us

AMITA Health ( www.AMITAhealth.org ) is a joint operating company formed by the Adventist Health System in Altamonte Springs, FL and St. Louis, MO based Ascension.

With the addition of Presence Health, AMITA Health is now the largest health system in Illinois, comprising 19 hospitals and more than 230 sites of care. The newly combined health system has 900 providers in its medical groups, more than 26,000 associates and 7,000 physician partners and now serves over 4.3 million residents in the greater Chicagoland area.

Job Description

Summary:

Sets strategy and leads utilization management practice for AMITA hospitals, through collaboration with all members of the health care team to coordinate timely and efficient delivery of required services to result in:

  • Positive patient health care outcomes

  • Appropriate reimbursement

  • Improved efficiency and standardization

  • Improved inpatient throughput from admission to discharge

  • Increased patient/health care team satisfaction

Responsibilities:

  • Leads and support UM managers and leaders in establishing policies and standard processes with respect to documentation of reviews, application of appropriate criteria and/or guidelines and documentation of review outcomes; applies constant evaluation of regulatory and payer changes to ensure UM team remains current with standards.

  • Identify and mitigate those clinical areas with the greatest level of care variation opportunities; monitors and implements solutions to ensure appropriate level of care to prevent pre and post claim denials.

  • Providing leadership in the planning, growth and operational management and team development

  • Drive towards optimal patient engagement and satisfaction and leverages people, process and technology to ensure efficiency and effectiveness

  • Model strong relationships with provider and clinical staff along with associated leadership and staff alike to support open collaboration and breakdown barriers to establishing joint workflow and policies with other departments/areas to influence decreased denials and appropriate reimbursement

  • Inform leadership regarding UM functions, challenges and accomplishments through routine and structured reporting

  • Conduct and support analysis needed to identify and mitigate changes needed to workflow, education and/or systematic enhancements.

  • Collaborate with legal and compliance to document/implement/update UM program and key policies.

  • Leads regional and enterprise initiatives providing expertise and performing root cause analysis where needed to implement sustainable improvements

  • Acts as a key contact and resource to investigate and follow up with external audits to address queries and perform needed analysis to respond and resolve findings as appropriate

  • Works closely with team, providers and education staff to identify, administer and measure needed training to ensure staff and team are up to current with regulatory and 3rd party payer requirements.

  • Actively manages external compliance and level of care support in collaboration with internal physician advisors.

Qualifications

Licenses/Certifications/Registration:

Required Credential(s):

  • Licensed Registered Nurse credentialed from the Illinois Department of Financial and Professional Regulation obtained prior to hire date or job transfer date.

Education:

  • Bachelor's Level Degree

  • Graduate of an accredited Nursing Program required

Work Experience:

  • Clinical nursing experience in a hospital and utilization review/case management experience required.

  • 5 years clinical nursing experience in a hospital setting

  • 3 years Utilization Review or hospital case management experience

  • 3 years management experience

How To Apply

We urge you to apply to any/all positions that you have interest in. If you fit the qualifications for the role, we will reach out to you. Please ensure you complete all required fields within the application (indicated with an asterisk), as well as additional information that is requested of you. Information that you offer us will better assist us in understanding your qualifications and fit for the position(s) you've applied for.

Equal Employment Opportunity

AMITA Health will provide equal employment opportunities (EEO) to all associates and applicants for employment regardless of race, color, religion, national origin, gender, sexual orientation, gender identification or expression, age, disability, marital status, amnesty, genetic information, carrier status or any other legally protected status or status as a covered veteran in accordance with applicable federal, state and local laws.