Director of Utilization Management

Nashville General Hospital is Nashville’s original community-based hospital. Joint Commission accredited, NGH accommodates a wide range of needs from emergency services and acute care to ancillary and ambulatory services. NGH maintains a strong commitment to the healthcare needs of Nashville and Davidson County’s underserved, while also providing care to all segments of the community.

About the role

The Director functions as the internal resource on issues related to the appropriate utilization of resources, coordination of care across the continuum, and utilization review and management. This role is responsible for carrying out assignments to assure success in financial management, human resources management, leadership, quality, and operational management objectives.

Responsibilities

• Lead and direct the coordination and facilitation of correct identification of patient status.
• Direct, implement, and integrate all Utilization Management (UM) functions including Denials Management.
• Manage, implement, and integrate Pre-certification functions.
• Collaborate with all members of the healthcare team, both internal and external customers.
• Participate in clinical performance improvement activities to achieve set goals.
• Oversee clinical documentation improvement services, ensuring medical records reflect the specificity of current conditions to allow for accurate coding of the patient’s health status.
• Plan, organize, and direct the organization’s operations and programs.
• Develop and implement consistent inventory and cost accounting policies, procedures, and operational reporting/metrics.
• Oversee and report on company results for senior management.
• Lead and direct the overall operation of the utilization management function to ensure consistency of policies, procedures, and workflows through IT integrations.
• Evaluate utilization management program effectiveness and recommend improvements, including needs analysis and planning.
• Ensure provider satisfaction with the utilization management program.
• Ensure utilization management targets for all products are met for the annual operating plan, state requirements, and financial management.
• Ensure the utilization management process is integrated with case management program and Clinical Documentation Improvement (CDI).
• Maintain compliance with National Committee for Quality Assurance (NCQA) standards for case management functions and The Joint Commission.
• Develop and implement methods, policies, and procedures to improve department efficiency and effectiveness.
• Identify quality and risk management issues and facilitate the collection of information for quality improvement and reporting.
• Review various reports and identify trends to assist in financial forecasting.
• Develop, organize, plan, and execute an action-oriented interdisciplinary Utilization Review Committee with consistent physician support.
• Ensure peer-to-peer completion in partnership with physicians.

Requirements

• Bachelor’s degree in nursing, related field, or equivalent experience.
• 5-7+ years of utilization management, clinical nursing, CDI, and quality improvement experience in a managed care setting.
• Two years of management experience preferred (preferably Utilization Review or CDI).
• Experience in CDI and coding in a healthcare setting.
• Current licensure or permit to practice as a Registered Nurse in the State of Tennessee or a compact state.

Benefits

• Medical, Dental, and Vision Insurance within the first 31 days of employment.
• Programs to reduce share of deductible and total out-of-pocket expenses.
• Metro Health Incentive Program – access to high-quality healthcare without incurring out-of-pocket expenses.
• Short and Long-Term Disability – up to 60% of eligible weekly pay.
• Life Insurance – basic life and AD&D coverage equal to $50,000 ($32,500 if age 65 or older), at no cost.
• 401K Retirement Plan – eligible up to IRS max limits and includes company contribution.
• Shift and Weekend Differential Pay offered on nights and weekends.
• Tuition Reimbursement for employee and dependents.
• 12 paid holidays – any holiday worked is another holiday banked.
• Flexible Spending Accounts.
• Free parking for all employees.