Director Inpatient Review

Job ID: J131437
Company: Highmark Health
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Oct 2, 2018

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Description

JOB SUMMARY

This job leads the Inpatient Care Management Program for the department, which includes management of RN care managers, Behavioral Healthcare Managers, and Administrative Support staff.  This includes the administration and management of assigned, select utilization management (UM) activities for the organization, including concurrent review, review of urgent and urgent admissions, continued stay review in all facilities assigned and discharge planning.  It may include any future affiliations with an inpatient UM program.  This job requires expertise in the areas of utilization management (UM), benefit interpretation, insurance industry regulations/compliance standards and personnel management.   Accountable for the operational excellence of the unit, control of administrative and care cost initiatives, system development and delivery of high quality outcomes, compliance with all state and federal regulations that affect UM activities and any needed reporting in a complete and timely manner. Ultimately responsible for compliance with NCQA, URAC, CMS, DOH and DOL regulations as related to UM activities.  Coordinates all inpatient care management activities to achieve and sustain operational excellence.  This is achieved through a collaborative approach with the management team to deliver an exceptional customer experience that promotes and facilitates appropriate resource utilization in the most appropriate care setting. Staff supervised by this individual may have relationships with a geographically aligned and assigned team responsible for population health management.

ESSENTIAL RESPONSIBILITIES

  • Performs management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
  • Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.
  • Strategic planning for the department; accountable for the operational excellence of the unit, control of administrative and care cost initiatives, system development and delivery of high quality outcomes, compliance with all state and federal regulations that affect UM activities and any needed reporting in a complete and timely manner.
  • Monitoring, reporting and controlling the departmental activities to optimize efficiency and effectiveness and improve outcomes for all members.
  • Development and periodic evaluation of administrative policies and procedures for the area and reviews the policies and procedures at least on an annual basis.  Ensures that UM requests are handled at the most appropriate staff level.
  • Communication with staff on area, unit and company activities.
  • Other duties as assigned or requested.

REQUIRED EDUCATION

Bachelor's Degree- Nursing (BSN)

PREFERRED EDUCATION

Health or business related field.

EXPERIENCE

Minimum:

  • 7-10 years' of health-related experience which must include at least 3 years' of recent management experience at a manager level in an operations environment
  • 7-10 year's experience in managed care

Preferred:

  • Certification in Care Management/Utilization Management
  • Demonstrated successful project management experience
  • Recognized as a clinical expert

KNOWLEDGE, SKILLS & ABILITIES (List the attributes required to perform the job through demonstrated service, education or training)

  • Strategic thinking
  • Excellent written and verbal communication skills
  • Ability to analyze data, measure outcomes and develop and implement action plans
  • Highly effective interpersonal skills
  • Demonstrated ability to be a change agent
  • Demonstrates the ability to intervene in crisis situations and multi-task in a fast paced environment

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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