Director Utilization Management

Job Description

Provides oversight and strategic leadership over the Patient Management and Utilization Review Departments across all sites. Includes Case Management, Utilization Review, and Social Work services. Responsible for oversight, standardization, and process improvement to ensure appropriate inpatient admission, level of care placement, coordination and receipt of services, psychosocial support, and safe, timely discharge planning and transitions of care across the continuum. Ensures effective interdisciplinary collaboration to address clinical, social, and resource needs, reduce barriers to care, and support optimal patient outcomes. Responsible for oversight of inpatient and transitional case management functions, including care progression, length-of-stay management, readmission reduction strategies, and post-acute care coordination. Provides leadership for Social Work services to ensure assessment and intervention related to psychosocial needs, discharge barriers, community resource linkage, and support for patients and families throughout hospitalization and transition. For Utilization Review and Utilization Management, ensures consistent practice and issuance of admission denials, concurrent denial notices, level of care determinations, ensuring patients are afforded appeal rights and financial responsibility is appropriately assigned as part of the broader system utilization management strategy. Responsible for timely concurrent and retrospective medical necessity appeals and denial management for all lines of business including quarterly insurance company audits, CMS RAC /MAC determinations. Responsible for review of data, determining trends, making recommendations to Senior Financial Team, implementing changes to meet demands. Works closely with Compliance to meet CMS, DOH & DNV regulations.

Education And Credentials

• Bachelor's in Nursing, Healthcare, Healthcare Admin or similar required.
• Registered Nurse NYS licensure required upon hire.
• Certification in Case Management or Hospital Leadership/Management preferred.

Experience

• 5 years of experience in Acute Hospital Case Management, Utilization Management, Discharge Planning required.
• 3 years of experience in management role of Case Management and Utilization Review Departments required.
• 3 years of experience in EMR, Microsoft Office, MCG criteria required.

Working Conditions

• Essential Weight Requirement - Sedentary (10 lbs)

Department

BGMC

Standard Hours

Bi-Weekly: 0.00

Weekend/Holiday Requirement

No

On Call Required

No

Scheduled Work Hours

8a-4p

Work Arrangement

Onsite

Union Code

N00 - Non Union

Kaleida Health’s Mission

To advance the health of our community, and we believe our diversity, equity, and inclusion (DEI) strategic work is mission- critical for the good of our workforce and the community who need and depend on our care and services. We understand that racism and health inequities stand firmly in the way of advancing the health of our community, and Kaleida Health envisions DEI as the pursuit of equity and restorative justice for every person. We will exemplify courage and accountability through both the professing and practice of our core values for our friends, colleagues, and community.

Pay

Salary Range: $114,338.25 - $157,212.41

Wage Determination

Based on factors such as candidate's experience, qualifications, internal equity, and any applicable collective bargaining agreement.

Recruiter

Casey M. Calandra

Grade

EX218

Requisition ID#

17678