Duke University Health System (DUHS) Job Descriptions
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DIR, UTILIZATION MANAGEMENT, DUHS
Job Title: DIR, UTILIZATION MANAGEMENT, DUHS
Job Code: 5567
FLSA: E
Job Level: J2
Revised Date: 06/01/2022
Supervisory Responsibility: Y
General Description of the Job Class
Leads and directs efforts related to Utilization Management at the Duke University Health System Hospitals. Provides oversight and ongoing supervision to Utilization Managers and Medical Chart Auditors. Ensures effective utilization of resources and staff. Liaison with appropriate Leadership at each Hospital.
Duties and Responsibilities of this Level
Personnel Management - Support the Entity department assistant director in daily operations of the Utilization Management staff and processes. - Available to assist assistant director and team leaders in problem solving ongoing issues related to the role and scope of UM. - Management of the evaluation process (midyear and annual) within area of scope. - Direct personnel oversight of team leaders assigned to support the ongoing operations of the department at each Entity. - Provides visible mentorship and guidance on an ongoing basis to ensure alignment with DUHS goals and expectations and development of staff within scope. - Monitors the KPIs as related to UM and recommends any additional BSC metrics to support Entity operational and strategic goals.
Education (Related to Utilization Management) - Coordinates certified InterQual Training program from the Health System. - Serves as certified InterQual Trainer for the department. - Develop curriculum for ongoing Utilization Management educational needs. - Coordinate with staff to identify subject matter and potential speakers - Investigate CE opportunities for UM staff - Compliance to departmental and regulatory expectations
Orientation (Related to Utilization Management) Revision and ongoing maintenance of department Orientation Program to the roles related to Utilization Management in conjunction with Entity team leaders.
Support training and orientation to all IT functionality to include: - Canopy Database - InterQual Criteria - RightFax - Provider Link - Maestro Care - Assurance of CMS Compliance Standards as related to reportable data capture and departmental IT systems
Utilization Review: Responsible for overseeing the coordination of utilization/medical necessity reviews for all payors (private, commercial, managed care, Medicare, Medicaid and self-pay) upon admission and concurrently throughout the inpatient admission in compliance with the DUHS Utilization Management Plan.
Liaison to external physician advisor group and coordinates communication and secondary review of clinical reviews.
Provides oversight of staff work to ensures that orders reflects the patient???s level of care, severity of illness and intensity of service utilizing McKesson Interqual?? criteria.
Communicates and collaborates with DUHS billing entity (PRMO), to ensure that all orders for status (IP/OPS/OBS) are accurately reflected in the billing system to ensure accuracy and congruence between the clinical and billing systems.
Provides formal and informal education to physicians to improve processes and compliance with utilization management plan.
Provides oversight and supports denials management processes by communication with appropriate DUHS and payor personnel
Provides education and consultation to appropriate staff to develop processes to avoid denials.
Provides feedback as requested to enhance negotiations with payors
Medical Chart Auditing/RAC
Provides support for conduction of retrospective review of medical records to ensure accuracy of patient status especially related to compliance with medical necessity criteria for short stay Medicare patients.
Serves as an active member of the RAC Oversight Committee, RAC Apparels Team and DUH Compliance Committee. Prepares reports/presentations as requested.
Supports and provides back up to those serving as primary clinical auditor and DUH representatives for medical necessity adjudication to the Recovery Audit Contractors and the Office of Inspector General in addition to other external sources of denial and medical necessity defense
Provides support to the Recovery Audit Contractors (RAC) initiatives by overseeing: - Coordination of RAC Appeals in conjunction with CM leadership and DUHS Compliance office - Reviews identified records for medical necessity utilizing McKesson Interqual?? criteria. - Communications of the results of review in accordance with RAC policies and processes within allowable timeframes - Utilization of DUHS approved documentation systems to support communication and work flow processes related to RAC appeals
DUHS Emergency Departments (ED) Utilization Management - Oversees the provision of support to the DUHS Emergency Departments (ED) to support the accuracy and timeliness of ED physician orders. - Oversees the provision support during established timeframes to support ED and admitting physicians/physician extenders in the determination and assignment of patient status. - Oversees the provision of education to ED physicians/physician extenders as needed via informal and formal education sessions to ensure understanding of patient status and to ensure compliance with the Utilization Management Plan.
Competencies and Ongoing Training (Related to Utilization Management) - Initial and ongoing verification of licensure - BLS - OESO - Diversity Training - Other DUHS related mandatory staff training
Regulatory Management and Oversight - Responsible for ensuring compliance with all regulatory aspects related to Utilization Management - Provides updates, education and direction related to regulatory change - Liaison with DUHS PRMO, HIM and Compliance Office
Miscellaneous - Supports Entity Shared Governance Council Structure - Represent DUHS Case Management Director as requested - Supports and participates in strategic planning for the DUHS Case Management Department
Required Qualifications at this Level
Education
BSN with Master's Degree in Healthcare-related field.
Experience
Minimum of 5 years of Acute Care Case Management/Utilization Management experience. At least 2 years of those years must be in a management role.
Degrees, Licensure, and/or Certification
Must have current or compact RN licensure in the state of North Carolina. Requires certification as a Case Manager or Accredited Case Manager or by December 31, 2017 for current staff. InterQual Certified Instructor preferred, or obtained w/in 1 year of hire.
Knowledge, Skills, and Abilities
Distinguishing Characteristics of this Level
The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.
Duke University is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions
Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
