Director, Utilization Review (Remote based in US) & 50%+ Travel

Under the direction of the VP Case Management & Continuing Care, the National Director, Central Utilization Review (UR) is responsible to oversee the development, implementation and performance management of Utilization Review services performed across all Tenet acute hospitals.

Under the direction of the VP Case Management & Continuing Care, the National Director, Clinical Denials is responsible to oversee the development, implementation and performance management of the Tenet Clinical Denials Prevention and Appeals Management program across all Tenet acute hospitals.  Leads Tenet case management services to promote appropriate level of care and length of stay processes and documentation to prevent clinical denials. 

Serves as the Tenet lead with Tenet National Director Utilization Review (UR), Sr. Director Revenue Cycle, hospital CFOs, Directors Revenue Analysis (DRAs), Directors of Patient Access and Managed Care Contracting to identify and address root cause for denial prevention and appeals. 

Serves as Tenet lead with Conifer Sr. Director Client Delivery for Tenet case management participation with denial management and denials prevention initiatives. 

Serves as a member of the Case Management and Continuing Care leadership team to improve Tenet hospital patient care performance as measured by key indicators including level of care, length of stay, patient throughput and compliance metrics. 

Leads continuous improvement initiatives and best practice strategies across all Tenet hospitals to achieve organizational goals through standardized systems and processes.  This position will partner with the market and hospital Administrative leaders to ensure the strategies are executed at the local level. He/She will work directly with Tenet, Conifer and USPI leaders to develop market strategies and tactics that are in alignment with company goals.  This leadership position builds strong performance-based relationships, manages through roadblocks and barriers to success, and builds processes and protocols to ensure continued sustainability of initiatives and business processes

 Key focus areas:

• Lead Tenet case management clinical denial prevention and management initiatives to support appropriate level of care.  Works closely with Conifer leaders to complete current state assessment, evaluate and implement leading practices for system standards and/or local market programs needed.  Evaluates clinical denials and appeals data, documentation and workflows to identify and address Tenet and/or Conifer process and performance gaps. 
• Manage Tenet Case Management contract with Conifer Resource Center (CRC) clinical appeals team to align and optimize case management processes related to revenue cycle, denial prevention and appeals.  Collaborates with CRC, Conifer Patient Access and Conifer leaders to monitor and manage key performance indicators to drive performance improvement and optimize workflow.  Leads collaborative analysis to identify and address root causes to improve performance and achieve organizational goals. 
• Lead successful denials prevention and performance improvement for Tenet hospitals.  Monitors and manages Tenet hospital performance to targets and leads corrective action plans needed to achieve organizational targets.  Collaborates with National Director Utilization Review to address local barriers and gaps in utilization review and authorization confirmation services.  Provides hospitals with performance data analytics to make decisions and drive improvement.   Works with hospital and market leaders to identify when improvement plan is needed and follows up to ensure successful execution.
• Work with National Director UR and Managed Care Contracting to identify and address payer and Independent Review Organization (IRO) issues. Collects and collates data from hospitals on payer issues and IRO results.  Provides Tenet managed care leadership team with data to address issues with payers including avoidable days, contract violations, and process issues. Provides input to contract language to support Tenet case management service needs.  Participates with Tenet Appeals Physician Advisor in identifying and addressing trends with payer medical directors.
• Provide oversight for Conifer processes related to Tenet Appeals Physician Advisor (PA) and potential account downgrades.  Supports the development and implementation of clinical appeals workflow to incorporate Tenet Appeals PA review prior to any account downgrade.  Works with Conifer and Tenet Appeals PA to identify opportunities for improvement including documentation and process.  Utilizes findings for process improvement and hospital PA and case management education.  Identifies trends to address with managed care contracting and plan medical directors.
• Uses lean tools to address performance barriers.  Develops and implements best practices to achieve organizational goals through effectively leading and managing change in a matrix environment.  Oversees the implementation of action plans and monitors progress toward goals assisting with addressing barriers and challenges and making adjustments as needed in a supportive, synergistic manner. Collaborates with medical and nursing leadership, as well as case management and continuing care team members to develop and implement methods to optimize use of hospital and post-acute services.
• Manages multi-disciplinary process improvement by utilizing excellent communication and servant leadership skills to challenge status quo and positively influence Administrative teams and physicians to change processes to improve performance.  May assist with the designing of and providing input needed for implementation and optimization of documentation systems (Cerner, PBAR, CarePort, etc.) to promote data integration, improve workflow and achieve key performance indicators. Fosters an environment that promotes team member support, partnership, growth and development by assessing the needs of the team and implementing programs to meet those needs. Provides analysis and education regarding regulatory and clinical changes impacting inpatient and post-acute care processes and reimbursement.  Provides education and tools for educating physicians and staff regarding programs and processes. 

Works in alignment with hospital and Conifer leadership teams and consistently demonstrates ability to:

• Conduct financial analysis, develop business plans and secure approval for programs
• Develop strategies to manage and prevent disputes and improve Revenue Cycle processes 
• Build trusting relationships with hospital and Conifer leaders to successfully implement new programs
• Build collaborative partnerships and lead cross functional teams to execute on plans and proposals
• Identify process inefficiencies via root cause analysis and design workflow to address opportunities identified
• Develop and implement action plans managing follow up to achieve outcomes
• Implement targeted process changes including ongoing metric monitoring and management to achieve goals and drive improvement

REQUIRED KNOWLEDGE AND EXPERIENCE:

 Education:  Advanced degree in Business, Nursing and/or Health Care Administration required.

Work Experience: 

• A minimum of 7 years hospital or health care leadership experience required. 
• Multi-site leadership experience preferred. 
• Experience successfully implementing clinical denial prevention programs for multi-hospital systems strongly preferred. 
• Project Management and Business Planning experience
• Strong analytical skills including use of Tableau and Excel
• Executive communication and presentation skills including ability to use PowerPoint.

 Certification: 

• Accredited Case Manager (ACM) or Certified Public Accountant (CPA) preferred.
• Six Sigma Geen Belt preferred.

Licensure:  Valid Registered Nurse (RN) preferred.

Compensation:

• Pay: $120,016-$191,568 annually. Compensation depends on location, qualifications, and experience. 
• Position may be eligible for an Annual Incentive Plan bonus of 10%-25% depending on role level.
• Management level positions may be eligible for sign-on and relocation bonuses.

Benefits:

The following benefits are available, subject to employment status:

• Medical, dental, vision, disability, life, AD&D and business travel insurance
• Manager Time Off – 20 days per year
• Discretionary 401k with up to 6% employer match
• 10 paid holidays per year
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance.
• For Colorado employees, paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.

Tenet Healthcare complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce.  If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date.  If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.

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