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Company: MedStar Medical Group
Location: Columbia, MD
Career Level: Director
Industries: Not specified
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Description

General Summary of Position
Responsible for overseeing utilization review operations across a defined group of hospitals within designated region of Maryland or the District of Columbia. Possesses deep knowledge and expertise specific to regulatory requirements of the region. Responsible for operationalizing strategic vision in partnership with system ACM leaders. Ensures consistent application of evidence-based review practices with oversight and performance management of UR RN teams. Drives performance aligned with regulatory and payor expectations, ensuring the delivery of high-quality care, operational efficiencies, reduction in avoidable utilization, and collaboration with clinical and operational stakeholders.


Primary Duties and Responsibilities

  • Directs and develops Utilization Review RN teams and their managers across service lines and region, ensuring operational efficiency and effective cross coverage.
  • Drives departmental strategy by analyzing key metrics and productivity data, identifying trends requiring rapid attention, and collaborating with stakeholders to implement real-time" solutions
  • Oversight and awareness of daily utilization review functions, including admission and continued stay reviews, appropriate level-of-care determinations, and pre-bill denial interventions
  • Serves as regional regulatory expert, monitoring policy changes, identifying trends requiring escalation, and maintaining compliance with state specific regulations including reimbursement structures, Medicaid requirements, and review protocols.
  • Manages UR RN float pool for region and ensures operational efficiencies and continuity across hospitals, including during volume surges, staff leave, or transitions.
  • Participates in the development of systemwide goals, policy updates, and technology implementations impacting utilization management. Leads initiatives to support department strategy, i.e., length of stay, observation conversion, timely reviews, and complex clinical cases by monitoring and reporting regional utilization metrics.
  • Serves as the primary contact for hospital executive and clinical leadership in the designated region, aligning utilization management strategies with local needs under the direction of senior leadership while promoting efficiency and regulatory compliance
  • Performance management of staff including float pool, ensuring licensure, competencies, and annual performance reviews.
  • Leads UM Committee, in partnership with physician advisor, for each hospital within region. Ensures connectivity and cadence of communication with each ACM Director, Physician Advisor, and CMO at each site. Responsible for escalations and connectivity to long length of stay and complex discharge team, as well as revenue cycle management.
  • Facilitates cross-functional collaboration with discharge planning/care coordination, physician advisors, and medical staff to optimize resource use.
  • Provides training, mentorship, and professional development opportunities for UR teams, supporting retention, engagement, and high performance. Leads onboarding and orientation, in partnership with other key leaders, for all new hire UR RNs.
  • Leads ongoing education and competency of entire UR RN team ensuring quality reviews and criteria usage. This includes interrater reliability, Sitel modules, Compass education modules, and updates to MCG and InterQual.
  • Ensures compliance with CMS guidelines, commercial payor requirements, and accreditation standards (i.e. Joint Commission)
  • Serves as the main point of contact for breast cancer patients meeting criteria of grant (low-income and minority), and their families. Uses the patient intake process and identifies needs and barriers that prevent patient from accessing care. Identifies and documents individual's barriers to learning. Ensures referrals to supportive care and support services (social worker, outside mental health, financial counseling, dietician, genetics counseling etc) are made in a timely manner.
  • Collaborates with local individuals, agencies, and organizations to facilitate access to community-based services addressing patients' barriers to care. Tracks patient progress and keeps other care team members informed. Identifies potential bottlenecks and performs appropriate interventions. Assists patients across healthcare disciplines to ensure appointments are made and kept. Prepares monthly report on performance timeliness of care (e.g. time from mammogram to biopsy and time from biopsy to surgery).
  • Helps patients prepare a list of questions and concerns to discuss with physicians prior to office visits. If necessary, accompanies patients to physician office visits and reviews information covered with patients afterwards. In conjunction with Navigation Team, develops a lay navigator training program.


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    Minimum Qualifications
    Education

    • Bachelor's degree Science in Nursing (BSN) required and
    • Master's degree in Nursing (MSN), Healthcare Administration, Business or related field required
    • One year of relevant education may be substituted for one year of required work experience.

    Experience

    • 5-7 years Utilization Management experience required
    • 3-4 years Nursing experience in acute care setting required and
    • 3-4 years progressive leadership/staff management experience, ideally in a multi-facility or system role required
    • One year of relevant professional-level work experience may be substituted for one year of required education.

    Licenses and Certifications

    • RN - Registered Nurse - State Licensure and/or Compact State Licensure in the State of Maryland or District of Columbia Upon Hire required and
    • Certification - Nursing Administration or Professional (Specialty) MCG or Change Health (Interqual) Certification Upon Hire preferred and
    • CCM - Certified Case Manager Upon Hire preferred and
    • Accredited Case Manager (ACM) Upon Hire preferred

    Knowledge, Skills, and Abilities

    • Excellent leadership, communication, and team development skills
    • Strong analytical and operational decision-making capabilities
    • Strong verbal and written communication skills with ability to effectively interact with all levels of management, internal departments and external agencies.
    • Ability to build comprehensive reports and effectively convey information to others
    • Working knowledge of various computer software applications preferred. individual with the ability to multitask.


    This position has a hiring range of $139,276 - $278,241

     


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