Director, Clinical Revenue Cycle

Essential Duties And Responsibilities

• Evaluate staff performance and productivity to ensure optimal use of resources
• Direct the overall activities of the Utilization Review team and implement efficiency measures
• Develop and achieve departmental goals and objectives to ensure organization metric goals are achieved
• Perform random audits to ensure appropriateness and timeliness of Utilization Review activities
• Maintain data and metrics to submit to the Revenue Cycle Committee
• Report and develop timely reports to submit to the Utilization Management Committee as directed
• Review Utilization Review plans annually, revising as necessary, and submit for approval by the Utilization Committee and Medical Executive Committee
• Absorb and maintain all appeals related to denials for all payers
• Implement strategies to reduce denials while optimizing revenue
• Ensure all hospitalized patients have the correct admission status so that an appropriate claim can be submitted to the payer
• Oversee and coordinate the Utilization Review program's development to include the hospital resources as necessary to support its success
• Facilitate and foster staff and physician participation in the development and/or process revenue cycle operations
• Engage in improvement activities and events that maximize financial support for the hospital
• Communicate Utilization Review results through appropriate committees
• Develop and implement a continuous process improvement plan

Qualifications

• Minimum Required Education: Bachelor’s degree in healthcare administration, nursing, health informatics, business, or a related field. Five years of management experience will be considered in lieu of degree.
• Preferred Education: Master’s degree
• Experience: Three (3) years of experience in direct patient care RN experience in an acute care environment. Five (5) years of experience in Utilization Review or Case Management department performing utilization review activities, with at least two (2) years of utilization review for an acute care environment.
• Certified Professional Coder (CPC) preferred
• Certified Case Manager (CCM) or Accredited Case Manager (ACM) within 2 years of eligibility
• If the degree is in Nursing, an active RN license is required