Utilization Management Director leads and directs the utilization review staff and function for a healthcare facility. Determines policies and procedures that incorporate best practices and ensure effective utilization reviews. Being a Utilization Management Director manages and monitors both concurrent reviews to ensure that the patient is getting the right care in a timely and cost-effective way and retrospective reviews after treatment has been completed. Provides analysis and reports of significant utilization trends, patterns, and impacts to resources. Additionally, Utilization Management Director consults with physicians and other professionals to develop improved utilization of effective and appropriate services. Requires a master's degree. Typically reports to top management. Typically requires Registered Nurse(RN). The Utilization Management Director manages a departmental sub-function within a broader departmental function. Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure. Deep knowledge of the managed sub-function and solid knowledge of the overall departmental function. To be a Utilization Management Director typically requires 5+ years of managerial experience. (Copyright 2024 Salary.com)
Job Summary
Reports directly to the JHH VP of Care Coordination/Utilization Management and indirectly to the JHBMC Senior Director of Care Management and is responsible for the coordination, management and success of The Johns Hopkins Hospital and The Johns Hopkins Bayview Medical Center Utilization Management programs. The Director develops and implements UM plans for both facilities in accordance with the mission and strategic goals, federal and state law and regulations, payor requirements and accreditation standards. The Director collaborates with clinical staff and payers to ensure medically appropriate and cost-effective care, through the application of nationally recognized utilization criteria. The Director collaborates with the Senior Physician Advisor and Physician Advisors to analyze trends and take appropriate actions to reduce risk to both organizations. The Director oversees and manages departmental operations for both facilities to assure the consistent and appropriate performance of prospective, concurrent and retrospective reviews. The Director collects, analyzes and reports on data related to the utilization of medical services and resources and prioritizes performance improvement initiatives based on data analysis. The Director identifies and actively oversees performance measures and outcomes for presentation at the Utilization Review Committee for both facilities. The Director provides leadership and strategic direction to assure professional responsibility, accountability and competency in the processes of utilization management. The Director is responsible for building effective relationships across all internal departments, the Health System, relevant outside insurance companies, and outside healthcare networks. This position requires a candidate with a significant background in utilization management and broad experience with third party practice standards, State and Federal regulations, and the formal denial/appeal process.
Qualifications
Completion of an accredited Registered Nursing Program required. Bachelor’s degree in Nursing, Healthcare Administration or Business Administration. Master’s degree preferred.
Licensed in the State of Maryland as a Registered Nurse (RN) required
Requires demonstrated experience in utilization review and appeals acquired through 10 or more years of progressively-responsible experience such as: