Utilization Review Manager - Clinical Performance - FT - Days

Stormont-Vail Health helps to take care of the health of residents in northeastern Kansas. Its facilities include the 590-bed hospital, an emergency and trauma center, an outpatient surgery center, and a network of community clinics located throughout the 12-county region. Its Cotton-O'Neil centers treat heart disease, cancer, skin problems, and digestive system ailments, as well as various clinics and ExpressCare locations. Specialized services include behavioral health, obstetrics, orthopedics, and physical and occupational rehabilitation. Geographic Reach: Stormont-Vail Health serves a 12-county area in northeast Kansas. Strategy: The health system pursues strategic partnerships and organic growth to keep up with demand. The system has partnerships with the Baker School of Nursing, Kansas Rehabilitation Hospital, and Mayo Clinic. In 2011, Stormont-Vail Health added pediatric critical care services to provide care to infants in the neonatal intensive care unit.

The Manager of Utilization Review works closely with the Director of Clinical Performance and the internal Physician Advisor to ensure compliance with regulatory requirements and in accordance with the hospitals objectives for assuring quality patient care and effective, efficient utilization of health care services. This role maintains up-to-date knowledge of the regulatory landscape, including CMS Conditions of Participation (CoPs), Medicare billing regulations, and The Joint Commission (TJC) standards. The Manager collaborates with Patient Financial Services, external Physician Advisor groups and the denial management team to ensure that utilization review processes support compliant denial prevention and accurate billing and reimbursement practices. They are responsible for organizing and overseeing the systems and services necessary for effective utilization review and case management operations. In addition, the Manager assumes day-to-day responsibility for process and performance improvement initiatives related to RN Case Managers involved in utilization management. This includes monitoring key performance indicators, identifying workflow inefficiencies, and implementing evidence-based strategies to enhance operational effectiveness. The Manager understands the compliance and financial implications of utilization review activities and demonstrates a strong commitment to continuous improvement. They proactively optimize workflows, support staff education, and ensure that documentation and review practices meet both clinical and regulatory standards while facilitating efficient care delivery and reimbursement.

Oversee Utilization Review Operations: 1. Manage daily operations of the utilization review team to ensure timely and accurate reviews, status determinations, clinical submissions and authorizations. 2. Supervise and mentor UR nurses and specialists, providing training and performance evaluations. 3. Facilitate the standardization of processes among all staff. 4. Ensures timely and accurate submissions by the UM staff to support authorization for services, in compliance with regulatory and payer requirements. 5. Collaborates closely with clinical teams, case managers, and payers to facilitate efficient care delivery and reimbursement. 6. Conducts internal audits of utilization review activities to ensure adherence to federal and state regulations and prepares for external audits or surveys. Applies organization-approved care guidelines (e.g., MCG) and other evidence-based utilization review criteria to guide decision-making and provide ongoing education to UM, Case Management staff, and other departments. Act as a liaison between clinical departments, finance, and administration to align utilization goals. Stay current with changes in healthcare laws, payer requirements, and clinical guidelines. Ensure compliance with CMS, Joint Commission, NCQA, and other regulatory bodies. Responsible and accountable for providing quality monitoring of the organization’s UM scorecard in collaboration with the Clinical Analytics team. Works closely with Clinical Performance Director and the Clinical Documentation and Health Information Management teams to support appropriate documentation to aid in medical necessity denial prevention. Works closely with the physician advisor to: 1. Assist with level of care and length of stay management. 2. Assist with the denial management process. 3. Review and make suggestions related to resource and service management. 4. Provide feedback to staff regarding level of care length of stay, and quality issues. 5. Review cases that indicate a need for issuance of a hospital notice of non-coverage/Important Message from Medicare. 6. Provide ongoing education related to necessary documentation to support acute care services. Technology and System Optimization: 1. Evaluate and implement software tools to streamline utilization review workflows. 2. Monitor system performance and recommend enhancements. Identifies quality, safety, patient satisfaction and efficiency issues leading to suboptimal care. Responds to and recognizes the need to engage leadership for complex case reviews and or system needs to support appropriate management of resources. Represents the UM/case management department on various hospital committees to enhance and foster optimal UM/case management outcomes. Creates an environment in which staff contributes to decision making.