From Bassett Healthcare Network's posting. “We” and “our” refer to the employer.
The best thing about this role
Are you looking to make a difference by improving the health of our patients? Here you will find an innovative culture that is patient-focused and dedicated to making a difference. We are committed to helping the population we serve, and our communities, achieve optimum health and enjoy the best quality of life possible.
What you'll do
Under the direction of the Vice President of Revenue Cycle, the Director of Utilization Management provides strategic and operational leadership for utilization management activities across a network of hospitals. Oversee contracted utilization management vendors and collaborates with physicians, Physician Advisors, CDI, Case Management, Revenue Cycle, Compliance, and Finance to ensure appropriate status determination, medical necessity compliance, denial prevention, and reimbursement optimization. Identifies opportunities and develops strategies that improve quality, efficiency, compliance, and financial performance.
Essential Job Functions
Provides strategic oversight of system-wide utilization management programs to optimize reimbursement, regulatory compliance, patient status determination, and resource utilization.
Directs and evaluates contracted utilization management vendor performance, including productivity, quality, staffing, contractual compliance, and operational improvement initiatives.
Develops and implements utilization management policies, workflows, and best practices across the healthcare network.
Oversee medical necessity review processes, denial prevention strategies, payer audit support, and appeals management activities.
Partners with Physician Advisors, CDI, and operational leaders to improve documentation quality, status determination accuracy, observation management, and length-of-stay performance.
Collaborates with Revenue Cycle leadership to identify and implement opportunities that improve reimbursement and reduce avoidable denials.
Develops and oversees utilization management analytics, dashboards, scorecards, and key performance indicators to support data-driven decision-making.
Analyzes utilization trends, financial outcomes, and operational performance to identify system-wide improvement opportunities.
Ensures compliance with CMS, Medicare, Medicaid, commercial payer requirements, InterQual, MCG, and accreditation standards.
Build collaborative relationships with physicians, clinical leaders, and operational departments to promote organizational goals and performance improvement.
Provides education and consultative support regarding medical necessity, documentation requirements, utilization management regulations, and payer expectations.
Performs similar or related duties as requested or directed.
What we need from you
Education:
4 Year / Bachelor's Degree In Nursing (BSN), required
Master's Degree In one of the following preferred:
Nursing (MSN)
Healthcare Administration (MHA)
Business Administration (MBA)
Experience:
Minimum 7 years of combined experience required in:
Utilization Review
Case Management
Minimum 5 years of experience in progressive healthcare leadership; multi-hospital and vendor oversight preferred
Licensure/Certifications:
NYS Licensure as a Registered Nurse (RN) required
ACM - Accredited Case Manager preferred
CCM - Certified Case Manager preferred
CMAC - Case Management Administrator Certification peferred
Skills:
Attention to Detail
Build Relationships
Communication
Computer Skills
Critical Thinking
Analysis & Evaluation
Data Management
Decision Making
Leadership
Manage People
Multi-Tasking
Maintain Confidentiality
Employee Relations
Reading/Writing/Comprehension
Systems Thinking
Strategic Thinking
Recognize Problems
Quality Assurance
Physical Requirements:
Sedentary Work - Exerting up to 10 lbs of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking or standing are required only occasionally, and all other sedentary criteria are met.
Occasional repetitive motion
Frequent hearing, and talking
Constant Typing/ Clerical/ Dexterity and Seeing/ Monitor/ Computer Use
Travel:
Occasional Travel - The job may require travel from time- to-time, but not on a regular basis.
Compensation
Total Rewards
Bassett Healthcare Network’s commitment to our employees includes benefit programs carefully designed with the needs and values of all our employees in mind. Many of the benefits we offer are paid fully or in large part by Bassett. Our generous benefits offerings include:
Paid time off, including company holidays, vacation, and sick time
Medical, dental and vision insurance
Life insurance and disability protection
Retirement benefits including an employer match
And more!
Specific benefit offerings may vary by location and/or position.
Pay Transparency
Salary is based on a variety of factors, including, but not limited to, qualifications, experience, education, licenses, specialty, training, and fair market evaluation based on industry standards. The above compensation range represents a good faith belief of the compensation range by Bassett Healthcare Network, and its entities and affiliates, at the time of this posting or advertisement.
Pay Range Minimum:
USD $127,936.66/Yr.
Pay Range Maximum:
USD $191,904.99/Yr.
We love the difference people bring
We provide equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, creed, sex (including pregnancy, childbirth, or related condition), age, national origin or ancestry, citizenship, disability, marital status, sexual orientation, gender identity or expression (including transgender status), genetic predisposition or carrier status, military or veteran status, familial status, status as a victim of domestic violence, or any other status protected by law.
Responsibilities
Under the direction of the Vice President of Revenue Cycle, the Director of Utilization Management provides strategic and operational leadership for utilization management activities across a network of hospitals. Oversee contracted utilization management vendors and collaborates with physicians, Physician Advisors, CDI, Case Management, Revenue Cycle, Compliance, and Finance to ensure appropriate status determination, medical necessity compliance, denial prevention, and reimbursement optimization. Identifies opportunities and develops strategies that improve quality, efficiency, compliance, and financial performance.
Essential Job Functions
Provides strategic oversight of system-wide utilization management programs to optimize reimbursement, regulatory compliance, patient status determination, and resource utilization.
Directs and evaluates contracted utilization management vendor performance, including productivity, quality, staffing, contractual compliance, and operational improvement initiatives.
Develops and implements utilization management policies, workflows, and best practices across the healthcare network.
Oversee medical necessity review processes, denial prevention strategies, payer audit support, and appeals management activities.
Partners with Physician Advisors, CDI, and operational leaders to improve documentation quality, status determination accuracy, observation management, and length-of-stay performance.
Collaborates with Revenue Cycle leadership to identify and implement opportunities that improve reimbursement and reduce avoidable denials.
Develops and oversees utilization management analytics, dashboards, scorecards, and key performance indicators to support data-driven decision-making.
Analyzes utilization trends, financial outcomes, and operational performance to identify system-wide improvement opportunities.
Ensures compliance with CMS, Medicare, Medicaid, commercial payer requirements, InterQual, MCG, and accreditation standards.
Build collaborative relationships with physicians, clinical leaders, and operational departments to promote organizational goals and performance improvement.
Provides education and consultative support regarding medical necessity, documentation requirements, utilization management regulations, and payer expectations.
Performs similar or related duties as requested or directed.
Qualifications
Education: 4 Year / Bachelor's Degree In Nursing (BSN), required
Master's Degree In one of the following preferred: Nursing (MSN)
Healthcare Administration (MHA)
Business Administration (MBA)
Experience: Minimum 7 years of combined experience required in:
Utilization Review
Case Management
Minimum 5 years of experience in progressive healthcare leadership; multi-hospital and vendor oversight preferred
Licensure/Certifications: NYS Licensure as a Registered Nurse (RN) required
ACM - Accredited Case Manager preferred
CCM - Certified Case Manager preferred
CMAC - Case Management Administrator Certification peferred
Skills: Attention to Detail
Build Relationships
Communication
Computer Skills
Critical Thinking
Analysis & Evaluation
Data Management
Decision Making
Leadership
Manage People
Multi-Tasking
Maintain Confidentiality
Employee Relations
Reading/Writing/Comprehension
Systems Thinking
Strategic Thinking
Recognize Problems
Quality Assurance
Physical Requirements: Sedentary Work - Exerting up to 10 lbs of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking or standing are required only occasionally, and all other sedentary criteria are met.
Occasional repetitive motion
Frequent hearing, and talking
Constant Typing/ Clerical/ Dexterity and Seeing/ Monitor/ Computer Use
Travel: Occasional Travel - The job may require travel from time- to-time, but not on a regular basis.
About this listing
LAYIQ is an independent job-discovery service. This listing does not imply a partnership with or endorsement by the employer. Review the original posting for current details and availability.
