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Manager, Utilization Management


Company

Lancaster General Hospital

Cost Center

2024 Utilization Mgmt-Admit/Denial

Supervisory Organization

PFS Front End Leadership

Grade

G16

Summary

This position is located in Lancaster, Pa

HOURS: Full- Time

POSITION SUMMARY: Responsible for the day to day operations of the Utilization Management Department.  Provides direction to assure denied authorizations are appealed in a timely manner, trends in denials are identified and forwarded to the appropriate department for follow up. Researches and coordinates completion of patient records required to appeal medical necessity denials for payment of claims. Identifies area for documentation and/or process improvement and promotes pro-active documentation compliance for reimbursement. The Manager will need to demonstrate dynamic ability to adapt to ongoing changes within the health insurance industry in order to effect and implement positive changes for the financial growth of Lancaster General Health. Keeps well informed of regulatory requirements/changes concerning MA, Medicare and third party payors.

ESSENTIAL FUNCTIONS: Qualified individuals must have the ability (with or without reasonable accommodation) to perform the following duties:

  • Manage all operational and management activities of the Utilization Management Admission Team and Denials Team, including the development and implementation of effective metrics to measure and monitor performance, team standard operating procedures (SOP), and compliance.
  • Manage all clinical activites related to patient care, establishing standards of care and documentation of such.
  • Manage staff hiring, work allocation, and scheduling, training and professional development, performance management and related management activities.
  • Identify areas for improvement of existing operational policies and SOPs utilizing LEAN methodology and follows through with implementation of changes to improve operational efficiency and patient satisfaction.
  • Revenue Cycle oversight for Access and Denial Management initiatives. Work closely with PFS leadership to ensure compliance with Federal and State regulations involving third party payers’ requirements. Evaluate and provide leadership to establish reasonable deadlines for account resolutions.
  • Assist the Director in managing the department budget. Manage functional operations that are consistent with budget allocations. Review, evaluate and report on expenditures for cost center. Review reports that routinely monitor and ensure compliance to fiscal budget.
  • Participates in the building of systems and processes to most effectively manage healthcare consumer needs and medical cost management (information systems, quality and utilization management).
  • Serve as a liaison to Physician Advisors, Care Management, Service Lines and other associated parties.  Build relationships for effective operations and best outcomes.
  • Develop working relationship with nursing, physicians and all appropriate internal and external departments on issues related to financial clearance, utilization management, medical necessity and readmissions to provide foundation for efficient case management services.
  • Work closely with Physician advisors to oversee and coordinate UM functions.
  • Other duties as assigned.

JOB REQUIREMENTS

  • Current licensure as a Registered Nurse, issued by the Pennsylvania Board of Nursing
  • Bachelor’s of Science in Nursing, Life Sciences, or Healthcare related fields
  • Minimum of five years of nursing experience which includes a minimum of three years in an acute care hospital setting
  • Three (3) years of management experience in nursing or related healthcare position.
  • Three (3) years of experience with utilization management
  • Three (3) years of experience working with physicians, staff and executive staff is required
  • Excellent written, interpersonal communication and negotiation skills. Strong analytical and data management skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Ability to advocate for the patient, as well as the hospital’s best interests.

PREFERRED QUALIFICATIONS:

  • Master’s degree.
  • Experience in the application of InterQual or MCG

LGH Full Time Posted on 02/18/2020