Mgr - Utilization Review - SMRMC Utilization Management - Saint Mary's Regional Medical Center

Join an award-winning team of dedicated professionals committed to our core values of quality, compassion and community! Saint Mary’s Health Network, a member of Prime Healthcare, offers incredible opportunities to expand your horizons and be part of a community dedicated to making a difference.

“As a long-standing community partner with a 114-year history, Saint Mary’s Health Network offers Northern Nevada inpatient, outpatient, ancillary, and wellness services. Nationally recognized and accredited by the Joint Commission, as well as named one of the Top 100 Hospitals by Fortune/Merative and America’s Best 250 hospitals by Healthgrades, Saint Mary’s Regional Medical Center is a 380-bed acute care hospital offering a robust line of inpatient, outpatient and ancillary services including a top-rated Center for Cancer, surgical and orthopedic services, and an award-winning Cardiology program and more. The health system, a member of Prime Healthcare, also operates a fully-integrated Medical Group, multiple urgent care clinics, freestanding imaging, lab, and primary care clinics. For more information, visit www.SaintMarysReno.com.”

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Utilization Review Manager is responsible for the oversight of third party payer utilization review (UR) and the denial management (DM) process. The Manager functions as an appeal/denial expert and takes an active role in managing the process and coordinating with Corporate Utilization and Authorization Appeals team. Provides supervision and direction for UR process along with analysis, resolution, monitoring & reporting of clinical denials. Facilitate peer to-peer communication and authorization appeals process following utilization review submission to respective insurances. Serves as a liaison between Case management, Business office and Coding teams to ensure timely reporting and tracking/ follow up of denials. Demonstrates appropriate knowledge of payer contract changes as they pertain to level of care determination and the appeal/denial process. Reviews and determines appropriate strategy in response to reimbursement denials. Coordinates data analytics to determine denial trends and reasons that could be reviewed with administration/ CMO and the Utilization Review Committee wherever applicable. Participate in regular Utilization committee and Case management meetings with stakeholders from all departments and Corporate leadership team to provide necessary education and discuss progress and protocols for Insurance authorization and denial prevention strategies. Keeps abreast with the ongoing education/training to stay current with emerging industry trends on utilization review and denials management. Performs ongoing audits, to monitor UR and appeal/denial process and develops process improvement plans for identified deficiencies. Able to work independently and use sound judgment. Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment. Performs other duties as assigned.

EDUCATION, EXPERIENCE, TRAINING

1. Medical Graduate, PA, or Nursing Graduate required.
2. ECFMG Certification / Bachelor’s or higher from a US-based accredited institution in a Health and Human Services field is highly preferred.
3. Utilization Review experience preferred.
4. Must meet the performance standards set forth by the Hospital/ Department at UR Coordinator I position for at least 6 months.
5. In order to be promoted to UR Coordinator II position; the Employee must meet certain performance standards as defined by the Hospital/Department.
6. In order to be promoted to Corporate Case Manager position; the Employee must meet certain performance standards as defined by the Hospital/ Department and obtain the Certified Case Manager credential. 1+ year of utilization review experience is highly preferred.

7. 1+ year of clinical experience in acute care setting preferred.
8. 1+ year of experience with ICD-10 and CPT coding in an acute care setting preferred.
9. Experience with use of an encoder software product for code assignment in an acute care setting preferred.
10. Excellent written and verbal communication skills. Excellent critical thinking skills.
11. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.
12. Ability to work independently in a time-oriented environment.
13. Computer literacy and familiarity with the operation of basic office equipment
14. Computer data entry with 10-key preferred, with accurate typing speed of 35 wpm preferred