Senior Director, Utilization Review – Remote

Beneath the route of the VP Case Administration & Persevering with Care, the Sr. Director, Utilization Evaluate (UR) is accountable to supervise the event, implementation and efficiency administration of Utilization Evaluate companies carried out throughout the Tenet enterprise. Leads Tenet hospital case administration operations to develop and implement centralized utilization evaluate and authorization administration companies by market or area to advertise applicable degree of care and forestall payer denials. Develops construction and processes to optimize staffing and productiveness. Leads analysis and implementation of instruments to leverage expertise to allow program accuracy and effectiveness. Serves because the Tenet lead with Tenet Nationwide Director Scientific Denials, Sr. Director Income Cycle, hospital CFOs, Administrators Income Evaluation (DRAs) and Managed Care Contracting to design concurrent processes to safe authorizations and forestall scientific denials. Serves as a member of the Case Administration and Persevering with Care management staff to enhance Tenet hospital affected person care efficiency as measured by key indicators together with degree of care, size of keep, affected person throughput and compliance metrics. Instantly reporting to this place are the market or regional centralized UR Staff Supervisor and/or Director positions.

Leads steady enchancment initiatives and finest apply methods throughout all Tenet and USPI hospitals to realize organizational targets via standardized techniques and processes.This place will accomplice with the market and hospital Administrative leaders to make sure the methods are executed on the native degree. He/She is going to work immediately with Tenet, Conifer and USPI leaders to develop market methods and techniques which are in alignment with firm targets. This management place builds robust efficiency based mostly relationships, manages via roadblocks and obstacles to success, and builds processes and protocols to make sure continued sustainability of initiatives and enterprise processes

Key focus areas:

1. Lead Tenet Utilization Evaluate Groups market construction and operations administration to successfully help utilization evaluate and authorization affirmation features to advertise applicable degree of care and forestall payer denials. Completes present state evaluation to outline present spend, decide main practices for system requirements in addition to native market applications wanted. Develops proposal(s) and secures approval for enterprise case to help a complete Tenet program to forestall payer denials. Works with group and market hospital leaders to develop and implement centralized utilization evaluate and authorization affirmation groups and processes to help hospital income cycle processes. Works with labor administration and human assets leaders to implement inside Tenet requirements for represented employees optimizing ability combine and productiveness.
2. Lead implementation of recent expertise to help utilization evaluate processes. Serves as Tenet chief accountable to steer new applied sciences for automating work processes and leveraging synthetic intelligence to handle UR processes by exception. This consists of main profitable implementation of recent techniques in addition to evaluating outcomes and deploying enterprise broad the place it is sensible. Helps enterprise case and secures approval for brand new applied sciences wanted to realize organizational targets.
3. Manages Case Administration operations with Conifer groups to align and optimize case administration processes associated to utilization evaluate companies. Collaborates with Conifer Affected person Entry and appeals staff leaders to observe and handle key efficiency indicators to drive efficiency enchancment and optimize workflow. Leads collaborative evaluation to determine and tackle root trigger to enhance efficiency and obtain organizational targets.
4. Lead profitable payer authorization efficiency enchancment for Tenet and USPI hospitals. Displays and manages hospital efficiency to targets and leads corrective motion plans wanted to realize organizational targets. Supplies management to handle native obstacles and gaps in utilization evaluate and authorization affirmation companies. Supplies hospitals with efficiency knowledge analytics to make choices and drive enchancment Works with hospital and market leaders to determine when enchancment plan is required and follows up to make sure profitable execution. Work immediately with USPI management to make sure standardization in course of and monitoring.
5. Works with Nationwide Director Scientific Denials and Managed Care Contracting to determine and handle Payer Portal and tackle payer points. Collects and collates knowledge from hospitals on payer points. Supplies Tenet managed care management staff with knowledge to handle points with payers together with avoidable days, contract violations, and course of points. Supplies enter to contract language to help Tenet case administration companies wants. Serves as advisor for Payer Portal content material and payer entry. Makes approval or denial choice for payer entry to case administration techniques.
6. Present operations oversight to the market Central Utilization Evaluate Staff Managers and/or Administrators in addition to Devoted UR websites native management. Helps the enterprise planning and progress for utilization evaluate companies to help Tenet enterprise. Supplies operations oversight to align processes throughout all Case Administration and Care Continuity applications to help enterprise progress, income cycle, regulatory compliance and high quality care throughout all websites and settings of care.

Makes use of lean instruments to handle efficiency obstacles. Develops and implements finest practices to realize organizational targets via successfully main and managing change in a matrix setting. Oversees the implementation of motion plans and screens progress towards targets helping with addressing obstacles and challenges and making changes as wanted in a supportive, synergistic method. Collaborates with medical and nursing management, in addition to case administration and persevering with care staff members to develop and implement strategies to optimize use of hospital and post-acute companies.

Manages multi-disciplinary course of enchancment by using wonderful communication and servant management abilities to problem established order and positively affect administrative groups and physicians to alter processes to enhance efficiency. Might help with the designing of and offering enter wanted for implementation and optimization of documentation techniques (Cerner, PBAR, CarePort, MIDAS, and many others.) to advertise knowledge integration, enhance workflow and obtain key efficiency indicators. Fosters an setting that promotes staff member help, partnership, progress and improvement by assessing the wants of the staff and implementing applications to satisfy these wants. Supplies evaluation and schooling relating to regulatory and scientific adjustments impacting inpatient and post-acute care processes and reimbursement. Supplies schooling and instruments for educating physicians and employees relating to applications and processes. Works in alignment with hospital and Conifer management groups and constantly demonstrates means to:

• Conduct monetary evaluation, develop enterprise plans and safe approval for applications
• Develop methods to handle and forestall disputes and Utilization Evaluate processes with Group Administrators of Case Administration (DCMs) and Income Cycle Administrators
• Construct collaborative partnerships and lead cross useful groups to execute on plans and proposals
• Determine course of inefficiencies by way of root trigger evaluation and design workflow to handle alternatives recognized
• Develop and implement motion plans managing comply with as much as obtain outcomes
• Implement focused course of adjustments together with ongoing metric monitoring and administration to realize targets and drive enchancment

REQUIRED SKILLS:

• A minimal of seven years hospital or well being care management expertise required.
• Multi-site management expertise most well-liked.
• Expertise efficiently implementing centralized Utilization Evaluate groups for multi-hospital system strongly most well-liked.
• Working data of CarePort and MIDAS documentation and reporting required.
• Undertaking Administration and Enterprise Planning expertise.
• Robust analytical abilities together with use of Tableau and Excel; govt communication and presentation abilities together with means to make use of PowerPoint.

Training/Certifications

• Superior diploma in Enterprise, Nursing and/or Well being Care Administration required.
• InterQual Licensed Instruction (IQCI), Accredited Case Supervisor (ACM) or Licensed Public Accountant (CPA) most well-liked, Six Sigma Geen Belt most well-liked.
• Legitimate Registered Nurse (RN) most well-liked

Compensation

A aggressive compensation program will likely be tailor-made to the chosen candidate. Base wage will likely be supplemented by a efficiency bonus and complete, well-rounded advantages program, which incorporates relocation help.

Journey

As much as 50%

Tenet Healthcare complies with federal, state, and/or native legal guidelines relating to necessary vaccination of its workforce. In case you are provided this place and have to be vaccinated underneath any relevant regulation, you may be required to point out proof of full vaccination or get hold of an approval of a non secular or medical exemption previous to your begin date. For those who obtain an exemption from the vaccination requirement, you may be required to undergo common testing in accordance with the regulation.

AONE19

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