Job Information

Providence Senior Director Utilization Management & Denials - Administration *Remote* in Seattle, Washington

Description

THE ROLE

The Senior Director Utilization Management & Denials - Administration is 100% remote. The role requires a broad knowledge and focus on Utilization Management and Denials principles such as performance improvement, healthcare finance (including contractual arrangements, utilization/quality metrics, and evidence of enhancing revenue cycle), regulatory standards, utilization management, industry benchmarks, demonstrated regulatory requirement experience and medical necessity criteria. The role requires the ability to consistently lead, support, and coach UM/UR staff and leaders. The position requires excellent interpersonal skills to collaborate with the physician community as well as other interdisciplinary groups. The role serves as a leader to create improvements in the quality and cost effectives of healthcare delivery.

Responsible to provide oversight and comprehensive strategic alignment, design, optimization, and improvement of the function. Direct responsibility and oversight for divisional pre-service and post-service utilization review, clinical claims audit, clinical appeals and reconsiderations, medical policy, and program management. Responsible for meeting Federal and applicable State regulatory requirements and quality accreditation standards while managing risks and complaints related to areas of responsibility. Is responsible for leading change acceleration processes for new program and project implementation efforts that span the division and the larger Providence Swedish delivery system. Sets direction and is focused on delivering quality improvement and expense management strategies through collaboration with other leaders to support the mission and strategic goals.

ESSENTIAL FUNCTIONS

  • Directs activities in UM/UR functions; Manages HR issues; Retention of staff is at 90% or greater; HR issues are dealt with in a timely manner and consistent with all PH&S policies and procedures.

  • Provides expertise in Utilization Management to Nursing and Medical Staff; Is viewed as a resource by Nursing and Medical staff leadership. Divisional liaison for all matters related to denials management. Provides key stakeholders (directors/managers, staff, physicians, community) education related to regulations/requirements or best practices.

  • Provides divisional leadership and strategic planning to operationalize standard utilization and appeals management within Providence North Division. Leads interdisciplinary efforts to address complex utilization management issues; Improvement in Long Length of Stay metrics. Leads and participates in division-side care management teams. Oversees Utilization Management standardization across the division with the aim to decrease total cost of care.

  • Develops an integrated process for aligning system, divisional and local goals and priorities via a strategic plan for Utilization Management. Annually reviews and updates strategic plan to reflect divisional/system/local objectives, changing needs and strategic opportunities. The Strategic Plan would include continued focus on standardization, advanced healthcare technologies, quality, safety, affordability and operating performance. Provides direct leadership and management; frequently working with executives, directors, managers and caregivers within the division and its affiliates to promote and facilitate program integration.

  • Accountable for budgetary compliance in departments reporting to the role; Performs at agreed upon metrics for departments. Proactively responds to fiscal changes by anticipating a need to adjust operations to ensure productivity and expense standards are met.

  • Continually identifies, plans, and implements process improvement. Provides direction and manages changes and updates to current processes, workflows, and policies and procedures to maximize caregiver and technology resources, and operational excellence. Facilitates collaboration and coordination among all North Division entities to develop and facilitate best practice(s) in utilization and appeals management.

  • Collects, monitors, and acts upon relevant data. Measures, analyzes and reports key metrics related to utilization management & appeals management.

  • Remains current in all regulations that impact areas of responsibility; Maintains a state of survey readiness at all times. Ensures that all aspects of federal, state and local compliance are met. Oversees and engages processes, procedures, and practices to minimize RAC, CERT, ADR regulatory denials. Implements appropriate procedures to mitigate clinical commercial and government denials.

  • Maintains strong relationships throughout Providence, and develops relationships with leadership across the continuum within the North Division. Builds positive working relationships with key managed care organizations to improve communication and decrease denials. Promotes and maintains positive relations with continuum of care providers.

  • Works directly with analysts to provide direction and consultation on utilization management systems and programs and quality initiatives. Identifies opportunities to appropriately coordinate services between inpatient and outpatient settings. Responsible for development and oversight of consistent regional reporting for utilization and appeals management related outcomes. This includes strong collaboration for management, engagement and ongoing development of technology capabilities (such as EPIC) to support UM functions, productivity and other work requirement.

  • Establishes and clearly communicates fair and consistent performance standards. Demonstrates an interest and an ability to encourage/coach/mentor caregivers toward personal and professional development and uses available resources for these purposes. Demonstrates service excellence and positive interpersonal relations in dealing with others, including patients/families/members, employees, managers, medical staff, volunteers and community members, so that productivity and positive relations are maximized.

  • Establishes and clearly communicates fair and consistent performance standards.

QUALIFICATIONS

  • Bachelor's Degree in Nursing, Healthcare administration/management, business administration, social science or other related field

  • Master's Degree in Nursing or other clinical field, healthcare administration, public health, business administration, social science or other related field (preferred)

  • Certification in utilization management or quality improvement (preferred)

  • 10 or more years of utilization management experience

  • 8 years of direct personnel management or supervisory experience with demonstration of supervisory and administrative ability documented

  • 5 years of experience in a clinical or acute care setting which includes understanding and delivery of evidence based medical practice, consultation with providers and health-based education to patients (preferred)

  • Experience in quality management principles, tools and methodology (Project Management, Lean Training, Six Sigma, Change Acceleration Process, PDCA Cycles, etc.) (preferred)

  • Experience with HEDIS, CAHPS, Medicare 5-Star, NCQU and/or URAC (preferred)

  • Knowledge of principles and practice of acute utilization management

  • Knowledge of evidence-based practice

  • Understanding of the care continuum and care transitions related to acute care ministries

  • A respected and trusted leader with a proven track record of achievement and reputation as a leader of change

  • Effective strategic planning, analytical, problem solving, writing, communication, presentation and organizational skills are required

  • Ability to manage multiple tasks simultaneously required

  • Must be able to build, cultivate and maintain key working relationships to drive expert to expert collaboration

  • Demonstrated knowledge of clinical information systems, program development, outcomes analysis and reporting, and quality improvement operations

  • Demonstrated working knowledge of health care cost containment concepts

  • Knowledge of Epic and other EMRs

  • Experience working in a union environment

  • Proficient with Microsoft Office (Outlook, Word, Excel, Power Point, Teams).

About Providence

At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.

The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

Check out our benefits page for more information about our Benefits and Rewards.

About the Team

Providence has been serving the Pacific Northwest since 1856 when Mother Joseph and four other Sisters of Providence arrived in Vancouver, Washington Territory. Today, Providence is the largest health care provider in Washington located in communities large and small across the state. In western Washington, Providence provides care throughout the greater Puget Sound from Snohomish County to Lewis County.

Our award-winning and comprehensive medical centers are known for outstanding programs in cancer, cardiology, neurosciences, orthopedics, women's services, emergency and trauma care, pediatrics and neonatal intensive care. Our not-for-profit network also provides a full spectrum of care with leading-edge diagnostics and treatment, outpatient health centers, physician groups and clinics, numerous outreach programs, and hospice and home care.

Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement.

Requsition ID: 254430
Company: Providence Jobs
Job Category: Health Information Management
Job Function: Revenue Cycle
Job Schedule: Full time
Job Shift: Day
Career Track: Leadership
Department: 3002 ADMINISTRATION WA PRMCE
Address: WA Seattle 1730 Minor Ave
Work Location: Swedish Metropolitan Park East-Seattle
Pay Range: $67.28 - $108.30
The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.
Check out our benefits page for more information about our Benefits and Rewards.