About Long Tail Health Solutions Inc.

Job Summary

Manages and provides oversight for the concurrent utilization review process and coordination of responses to all requests and regulatory requirements for commercial payors, the Centers for Medicare and Medicaid Services (CMS), audit and denial programs.

Education and Experience

• Bachelor’s degree in healthcare related field; nursing degree preferred; Master’s degree preferred

• 3-5 years of progressive experience in healthcare leadership

• 3 years of utilization review, denial recovery or case management experience

• ACM or CCM certification preferred

Knowledge

• Knowledge of hospital revenue cycle and utilization review

• Proficient with principles of all payer types including managed care, Medicare/Medicaid, and private insurer reimbursement rules
  

• Knowledge of medical necessity criteria and payer reimbursement arrangements
  

Skills

• Project management to ensure budgetary constraints and plan deadlines are met timely. Ability to oversee team and guide them to successful outcomes with work consistency, process improvement changes, and efficiency optimization.
  

• Advanced problem solving to address complex cases, reimbursement trends and quality assurance.

• Customer service for providing solutions to payers, patients, clients and team members.

• Organizational skills to manage multiple tasks balancing team’s strength to match department’s workload.
  

• Interpersonal skills to help interact and work with team and clients effectively.

• Critical thinking to optimize day to day assignments, make necessary decisions on high risk/high dollar cases and respond appropriately to demanding client and payer needs.

• Interviews, hires, orientates, trains, develops and evaluates the performance of and, when necessary, disciplines and/or discharges department personnel. Provides direction, as necessary, to staff regarding sensitive and/or complex work, related problems, resolves complaints and response to inquiries regarding department operations.
  

• Provides ongoing education and coaching of department staff

• Maintains a working knowledge of all current best practices for commercial and governmental payer denials management.
  

• Disseminates current regulatory and payer trending information as formal education to appropriate staff.
  

• Evaluates team member comprehension and understanding of education.

• Orchestrates performance of concurrent clinical reviews for utilization review using appropriate screening criteria completes necessary review as identified and required by payers until patient discharge. Reviews must be thorough and complete on a timely basis.
  

• Communicates with team members including physicians, RN's, utilization review staff, case managers, social workers, and other applicable interdisciplinary team members regarding utilization issues.
  

• Continual tracking of in-house patient statuses and communicates with appropriate team members including you our staff and third parties regarding status issues.
  

• Orchestrate continual reviews of in-house observation patients.

• Create pathways for utilization review team to identify and tracks avoidable days and care optimization opportunities. Evaluate information gathered by team and identify trends and utilization management opportunities.
  

• Work with inpatient care coordination team to help identify and reinforce proper utilization management of patients.
  

• Develops and monitors concurrent review process for accuracy and quality.

• Ensures all days are approved appropriately before billing.

• Ensure compliance with federal state and 3rd party utilization management regulatory requirements.

• Leads and assists the utilization review staff to overturn denials concurrently.

• Provides oversight and assistance staff in the investigation of denials received for lack of medical necessity, continued stay, pre-certification through review of medical record, physician communication, and internal department communication.
  

• Provides guidance and support for the staff with writing appeals and commercial payers.

• Educate departments in which billing, and charge errors occur.

• Participates in hospital utilization review committees.

• Monitors and tracks the volumes of referrals sent to physician advisor services, concurrent and retrospective denials, and performance on overturn/success rates.
  

• Ensures all cases include documentation to prove necessary regulatory and/or payer specific guidelines have been followed prior to billing so that to be readily available in the event of an audit and/or denial of payment.