Manager-Utilization Review and Insurance Verification, Palos Community Hospital

Benefits

• $10,000 Tuition Reimbursement per year ($5,700 part-time)
• $10,000 Student Loan Repayment ($5,000 part-time)
• $1,000 Professional Development per year ($500 part-time)
• $250 Wellbeing Fund per year($125 for part-time)
• Matching 401(k)
• Excellent medical, dental and vision coverage
• Life insurance
• Annual Employee Salary Increase and Incentive Bonus
• Paid time off and Holiday pay

Northwestern Medicine is powered by a community of colleagues who are purpose-driven and committed to our mission to deliver world-class care. Here, you'll work alongside some of the best clinical talent in the nation leading the way in medical innovation and breakthrough research with Northwestern University Feinberg School of Medicine.

We recognize where you've been, and we support where you're headed. We celebrate diverse perspectives and experiences, which fuel our commitment to equity and culture of service.

Grow your career with comprehensive training and development opportunities, mentorship programs, educational support and student loan repayment.

• Create the life you envision for yourself with flexible work options, a Reimbursable Well-Being Fund and a Total Rewards package that support your physical, mental, emotional and financial well-being.
• Make a difference through volunteer opportunities we offer in local communities and drive inclusive change through our workforce-led resource groups.

From discovery to delivery, come help us shape the future of medicine.

Description

The Manager-Utilization Review and Insurance Verification reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

Responsibilities:

• Lead, plan, and coordinate the Quality Utilization programs at the business unit level, in collaboration with the System Director of Clinical Documentation and the Medical Director(s) of Quality Utilization.
• Scope includes all functions which support medical necessity documentation within the patients medical record.
• Scope includes all practitioners, clinicians and others participating in delivering or supporting patient care, including those privileged through the medical staff, trainees, students, employees, volunteers.
• In collaboration with the regional leadership, develop, implement, manage and achieve annual Quality Utilization plans, and other supporting plans.
• Collaborate in advancing the work of business unit functions, including Quality Utilization, Clinical Documentation Improvement, Coding, Quality, Compliance, and other activities across the region.
• As assigned, assume leadership in advancing these programs on a regional or system-wide level.
• Design, lead, implement, teach and monitor NM Quality Utilization practices, policies, protocols and methodologies.
• Staff and support the Quality Utilization Committee.
• Manage/oversee the subcommittees of the Quality Utilization Committee.
• Assure and support adherence to Medicares Conditions of Participation.
• Assure and support accurate, appropriate and timely billing of inpatient and outpatient observation patient hospitalizations, including concurrent denial management as needed.
• Design, lead, implement, teach and monitor use of technology and data driven approaches to adhering to government rules and regulations and commercial payer guidelines.
• Identify, develop, and implement key strategies to leverage the electronic health record (EHR) and other tools to facilitate accurate representations of medical necessity and care delivered within the medical record.
• Partner with regional leadership to identify, prioritize by clinical area, and facilitate improvements in utilization review.
• Assure and support practices to promote accuracy of publicly reported data.
• Partner with leaders from Revenue Cycle and Finance to identify, respond to and learn from post-payment denials.
• Assist with appeal activities as necessary.
• Implement surveillance and reporting to identify areas of concern and strength.
• Monitor internal and external trends to identify priorities.
• Assure and support training for the Quality Utilization Team.
• Plan and lead improvement initiatives, innovation and transformation activities.
• Recruit and develop staff, teach/orient/train, manage financial and human resources efficiently and effectively.
• Maintain high levels of staff engagement and performance.
• Collaborate effectively across the system, including but not limited to directors and managers of quality / process improvement / analytics, chief medical officers, chief nursing executives, operations executives.
• Advance the standard of quality and safe patient care across NM through innovation, learning and shared deployment of best practices.

Qualifications

Required:

• Bachelors degree in nursing.
• 3+ years of experience in related field (i.e. clinical quality/utilization, patient safety) including evidence of effective improvement initiatives.
• Leadership, personnel management, and change management skills.
• Project management, facilitation, and analytical skills.
• Statistics, quantitative and analytic skills relevant to the role.
• High level of energy and enthusiasm; flexible/adaptable ability to work with diverse group of healthcare professionals in a matrix environment.
• Effective problem solving and multi-tasking, verbal and written communication skills.

Preferred:

• Masters degree in relevant field.

Equal Opportunity

Northwestern Medicine is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.