NHRMC, established in 1967 in Wilmington, NC, is recognized as a preeminent healthcare organization focused on leading our community to outstanding health. We have an 855 bed network of hospitals and multi-specialty physician group practices with more than 200 physicians. With a network of primary, specialty, neighborhood clinics and regional medical centers; you will find our culture is the very definition of best in practice. Join us and find out how many ways NHRMC offers you the chance to focus on what really matters - our patients and community.
About the Job
Location: New Hanover Regional Medical Center
Department: Utilization Management
Full Time Equivalent: FTE: 1.000000
Work Type: 64 to 80 Hours Pay Period
Work Schedule: 8HR DAY - Most of shift btwn 7A-3P
Exempt from Overtime: Exempt: Yes
What You'll Do
Responsible for the leadership, planning, daily operations, employee relations, financial management, maintenance of standards of performance, and customer satisfaction for the hospital Utilization Management program. Requires a high level of clinical proficiency necessary for the oversight of the day-to day processes of the utilization management program departmental planning and administrative activities.
1. Oversees hospital Utilization Management (UM) program including medical necessity clinical review and determination of appropriate patient status. 2. Maintains up to date knowledge of CMS and other appropriate payer regulations. 3. Oversees compliance with Medicare and Medicaid regulations and other regulatory agencies as they relate to payment for hospital stays. 4. Regularly updates hospital UM plan in coordination with Director and Medical Director, and ensures compliance with same. 5. Collaborates with UM physician advisors on regular basis to maintain integrity of UM program. 6. Coordinates the hospital Medicare A to B billing process for Medicare self denials. 7. Ensures appropriate use of the hospital Medical Necessity Screening tool (MCG) through staff education, inter-rater reliability testing and review of regular reports. 8. Serves as subject matter expert to other departments related to patient status orders and electronic medical record workflows related to billing for patients in a bed. 9. Collaborates with Patient Financial Services and Fiscal in the review of and recommendations for the utilization management component of payer contracts. 10. Collaborates with managed care agencies and commercial payers to ensure best practice for clinical reviews to prevent denials. 11. Supervises denials management of medical necessity denials including concurrent medical necessity denials, retrospective medical necessity denials and submission of formal appeals for same. Represents Clinical Resource Services on hospital Denials Management Steering Committee and the Recovery Audit Committee. 12. Participates in and supports the attainment and analysis of data to minimize variations in practice patterns in determining the appropriate level of care and efficient resource utilization. Develops and provides reports as needed to monitor key performance program indicators. 13. Responsible for evaluating department performance in relation to desired outcomes, based on benchmarking data in coordination with the Director and Medical Director. 14. Establishes and monitors departmental objectives relative to the organizational goals. 15. Maintains departmental budget within established guidelines. 16. Demonstrates effective leadership and communication skills to collaborate with a variety of persons, including the patient, public, coworkers, guests, payers, outside agencies and medical staff. 17. Hires and retains competent, service excellence oriented staff. 18. Ensures staffing is sufficient and employees are adequately trained to provide high quality services to patients and their families, physicians, other healthcare providers. 19. Responsible for evaluation and disciplinary process. 20. Organizes and performs work responsibilities effectively and efficiently. 21. Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence. 22. Responsible for analysis of data: development, analysis and communication of departmental scorecard. 23. Participates in and supports the attainment and analysis of data to minimize variations in practice patterns and optimize lengths of stay and resource utilization 24. Oversight of Physician Resident education of UM processes and patient status compliance. Present education at Physician Resident Education program. 25. Collaboration / education to all service line leaders on issues related to Utilization Management and support initiatives for care improvement. 26. Follow-up on Medical Necessity reviews post-acute as appropriate. 27. Oversight of Medical Necessity clinical reviews of elective procedure to ensure compliance with CMS regulations. 28. Works collaboratively with service line leaders to support patient throughput improvement efforts.
* Registered Nurse
* Bachelor of Nursing
1. Education: Graduation from accredited School of Nursing. BS in clinical discipline required. MSN, MHA, or master’s degree in an equivalent field preferred. 2. Licensure / Certifications: Current license to practice professional nursing in State of North Carolina. Certification in Case Management preferred. American Heart Association BLS required. 3. Experience: 5-10 years increasing management experience in Case Management or Utilization Management. Must have recent experience leading a case management department in an acute care hospital, preferably of comparable size and services. Documented ability to achieve positive outcomes related to length of stay, denials management, and the like.
Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
Performs other duties as assigned.
Individual will possess commensurate combination of education, experience and qualifications.
This position description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications which may be required of the employee assigned to the position. Depending on the location of the job, duties may vary. Receipt of the job description does not imply nor create a promise of employment, nor an employment contract of any kind; my employment with the Company is at will.
- Member Top 100 Hospitals – In 2016 NHRMC was recognized as a Top 100 Hospital demonstrating significant investment and financial sustainability for the communities we serve.
- Newsweek's 2020 list of Best Maternity Care Hospitals - NHRMC Betty H. Cameron Women's & Children's Hospital was named as a Best Maternity Care Hospital by Newsweek.
- Forbes America’s Best Large Employers 2018 and 2019- Link
- Becker’s 150 Top Places to Work in Healthcare- Link
- Healthgrades Outstanding Patient Experience
Consider a career at NHRMC and become part of this award winning team!