General Summary of PositionThe Assistant Vice President of Utilization Management is responsible for hospital utilization review services across MedStar Health enterprise--includes strategic oversight, program development, staff oversight and performance management, subject matter expertise, metric development, implementation,& mitigation actions. Responsible for the overall planning, direction, and implementation of roles, standardized processes, and programs for the Utilization Management team to ensure medically appropriate and cost-effective care. Collaborates and partners with physicians, case management, and hospital leadership, finance, compliance, population health, and other pertinent stakeholders/ committees to ensure an aligned approach to patient care with providing efficient, quality care, discharge planning, and utilization review
Primary Duties and ResponsibilitiesProvides strategic leadership and develops and implements short-and long-term strategies, policies, and best practices for the Utilization Review Program across MedStar Health with an emphasis on a data-driven approach Oversees and implements daily utilization review RN assignments and caseloads. Serves as a subject matter expert for escalations from Utilization Review and Appeals RNs, Physician Advisors, medical staff, revenue cycle and case management leaders. Operational oversight and implementation of standardized utilization review practices for medical necessity reviews, secondary reviews, peer to peer discussion with payors, pre bill denial interventions in collaboration with UR/CM/RCM and medical staff, denial root cause determination and upstream process improvementIn collaboration with system ACM leaders and other key stakeholders, provides strategic direction and implementation of LOS and complex discharge management initiatives and best practices. Identify and address clinical over or underutilization trends, issues/barriers to discharge, delays in service, with specific clinical departments or other hospital-based processesProvides direct consultation and education for the ACM team, medical staff and other key collaborators on regulatory requirements, appropriate utilization of hospital services, medical necessity documentation, denial management practices, and the goals/processes of MedStar Health's Acute Case Management and Physician Advisor Programs Provides strategic & operational leadership to the optimization of the ACM platform in Cerner and emerging technologies to enhance real-time decision making, reduce administrative burden, and improve utilization review efficiency.Promote hospital adherence to ensure compliance with CMS policies and updates regarding inpatient admissions, IPO list, observation status, as well as the appropriateness of continued hospital stay. Maintains a working knowledge of criteria and coverage guidelines used in UM process, including Federal and State regulationsEncourages a collaborative approach to patient care with the goal of providing efficient, quality care, discharge planning, and utilization review Collaborative approach to developing and implementing metrics at the department and individual level to drive and assess performance of the Utilization Review Programs. Oversight and management of utilization review RN staffing schedules, workload distribution, and RN performance.Responsible for system coordination, management, and success of MedStar Health's Utilization Management program across the UM continuum in accordance with the mission and strategic goals of the organization, federal and state law and regulations, payer requirements, and accreditation standards. Plans for and responds to regulatory changes and audit activities to reduce financial risk and improve revenue recovery.Educates and partners with physician and nursing leadership, finance, compliance, and population health, and other pertinent stakeholders/committees
Minimum QualificationsEducationMaster's degree In Nursing (MSN), Healthcare Administration, Business Administration or related field required
Experience10+ years Progressive leadership experience in healthcare administration required and5-7 years progressive leadership experience in utilization review and appeals at health system level managing multiple hospitals
Demonstrated record of accomplishment in health care administration or clinical practice, and innovative practice delivery
Experience with MCG and Interqual criteria
required
Licenses and CertificationsRN - Registered Nurse - State Licensure and/or Compact State Licensure In state of Maryland or District of Columbia Upon Hire required
Knowledge, Skills, and AbilitiesExcellent communication and presentation skills, strong interpersonal skills. Leadership skills and demonstrates ability to lead teams and work effectively in a team, matrixed environment. Demonstrated ability to develop and implement strategic initiatives.
Proven ability to influence others, manage, and resolve conflict, and collaborate effectively as necessary to execute goals. Independently solves complex problems related to utilization management, human resource issues, payer and managed care, and care coordination. Extensive knowledge of management principles, including budgeting, human resource planning, and other operational techniques required to run a large clinical enterprise.Improvement mind-set focused on driving change using actionable data & lead change
This position has a hiring range of $181,600 - $245,600