Director, Authorization Management

The Director Authorization Management leads and manages a team composed primarily of care managers (including system care managers), utilization review nurses (RN, LPN) and insurance verification representatives. This team will develop processes for prospective, concurrent and retrospective utilization review. They will provide timely notification of admission to third party payors and managed care companies. The team will work closely with the hospital-based care managers to provide clinically accurate, timely and meaningful medical inpatient/observation reviews to payors in order to obtain admission approval. The Director Authorization Management collaborates with staff external to the organization (payors), as well as, members of the NHC health care team (Patient Financial Services, Registration, Health Information Management, Care Management). As a key leader in Norton Healthcare's Improvement Network, the Director Authorization Management, will coach and facilitate this team in performance improvement initiatives, to ensure high quality outcomes and exceptional patient care. Tracking, trending and reporting key financials (lost revenue due to denials) will be required . The Director Authorization Management will provide guidance to staff on preventing and appealing denials, and educate on medical necessity criteria such as InterQual and/or Milliman Care Guidelines.

Key Accountabilities:

• Provides annual performance evaluations for direct reports/ provides feedback to other system leaders as requested. Evaluates annual employee engagement results and works with teams to establish action plans to ensure workforce concerns are being addressed. Mentors/coaches team as needed to ensure that members have the right tools and training to deliver on expected goals and quality patient care.
• Identifies and coordinates improvement opportunities and leads formal groups to identify processes to reduce insurance denials/loss of revenue. Continually assesses the insurance authorization process for opportunities to streamline and eliminates duplication of work. Collaborates with staff/leaders in other departments (both external and internal to NHC). Provides appropriate feedback to the staff as needed regarding payor guideline changes.
• Responsible for achieving annual department performance metrics developed by system leadership, and the management of financial resources to meet and exceed the expected budget (efficient utilization review).
• Demonstrates critical thinking, problem solving and prioritization skills. Uses positive communication techniques, is skilled in empathizing, listening and supporting while maintaining strict professional boundaries. Manages the department by leading as a role model. The leader holds themselves accountable to the same performance expectations as those reporting to him/her.
• Assists staff to ensure proper hospital/payor authorization requirements are met. Maintains current organized databases regarding payor requirements, reviews, contacts, decisions and appeals. Is knowledgeable of managed care contracts, government payment methodologies and coverage guidelines.

Required:

• Three years management in care management/care coordination setting
• Bachelor Degree
• Registered Nurse

Desired:

• Master Degree
• Certified Case Manager OR Certified Professional in Denial & Appeal Management