Project UM Audit & Documentation Director

About the role

The Project Utilization and Documentation Director supports UM Leaders and their department operations at assigned facilities, ensuring medical necessity, compliance, and financial performance. This role utilizes Behavioral Health treatment and medical necessity expertise, payer audit readiness, and documentation excellence to optimize reimbursement at facilities in collaboration with facility leaders and corporate partners.

Responsibilities

• Audit patient charts at assigned facilities to ensure accuracy, completeness, and compliance with regulatory standards and practice guidelines.
• Identify discrepancies or missing information and take corrective action with team members providing care at the facility.
• Perform facility audits of clinical and financial information related to denial management including length of stay, medical necessity documentation, precertification, concurrent authorizations, compliance with Medicare Certification/Recertification, Medicare Internal Audits, and compliance with EMTALA standards.
• Ensure that all records and documentation practices comply with HIPAA regulations and other relevant healthcare laws and standards.
• Conduct regular quality checks on medical records and scanned documents to maintain high standards of accuracy and completeness. Report any issues or concerns in real-time to care providers and clinical leaders at the facility.
• Generate and maintain reports on chart audits, compliance issues, and other relevant data. Provide insights and recommendations to improve record-keeping processes and documentation practices.
• Serve as a resource for education and training to physicians and clinical staff on current documentation and regulations.
• Serve as a resource for education and training to physicians and clinical staff on current documentation and regulations.
• Support the development and sustainment of action plans for the resolution of problematic issues or to address areas of compliance vulnerability.
• Aid in the development of Process Improvement practices in facilities and maintenance of same including analysis of data and prioritization of efforts as needed.
• Collaborate with clinical services to ensure clinical documentation provides rationale to ensure authorization is obtained via successful process and utilization of the patient’s individualized benefit is achieved.
• Provide consultation and guidance regarding written level of care guidelines for a variety of payors.
• Provide consultation and guidance regarding the appeal process. Assist facility UM staff in creating effective appeal letters.
• Ensure proper use of Medhost, the Medhost dashboard, and Sharepoint.
• Maintain current knowledge of applicable regulations and regulatory updates in the behavioral health field.
• Perform other duties as assigned.

Qualifications

• Bachelor’s degree in Nursing or other clinical degree required.
• At least 5 years’ Supervisory experience in Intake and Utilization Management/Review or Case Management preferred.
• Strong knowledge of payor clinical guidelines and audit processes, experience writing appeal letters, and strong working knowledge of documentation that meets payor reimbursement standards.
• Significant behavioral healthcare experience in a variety of settings and service lines.
• Knowledge of insurance billing requirements preferred.
• Effective and accurate oral and written communication skills.
• Possesses the ability to effectively influence facility leadership, teams and corporate partners to embrace required operational shifts by clearly articulating the long-term benefits of the new expectations.
• Knowledge of office administration procedures with the ability to operate most standard office equipment.
• Ability to work professionally with sensitive, proprietary data & information while maintaining confidentiality.
• Excellent interpersonal skills including the ability to interact effectively and professionally with individuals at all levels; both internal and external.
• Self-motivated with strong organizational skills and superior attention to detail.
• Must be able to manage multiple tasks/projects simultaneously within inflexible time frames. Ability to adapt to frequent priority changes.