System Director, Authorization Management & Pre-Service

Job Description

The System Director Authorization Management & Pre-Service leads and manages a team composed primarily of denial nurses, utilization review nurses (RN, LPN), pre-service and insurance verification representatives. This team develops processes for prospective, concurrent and retrospective utilization review. They provide timely notification of admission to third party payors and managed care companies. The team works closely with the hospital-based care managers and clinical offices to provide clinically accurate, timely and meaningful clinical reviews to payors in order to obtain authorizations. The System Director Authorization Management & Pre-Service collaborates with staff external to the organization (payors), as well as members of the Norton Healthcare team (Patient Financial Services, Registration, Norton Medical Group, Health Information Management, and Care Management). As a key leader in Norton Healthcare's Improvement Network, the System Director Authorization Management & Pre-Service, 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) is required. The System Director Authorization Management & Pre-Service provides guidance to staff on preventing and appealing denials and educates on medical necessity criteria such as InterQual and/or Milliman Care Guidelines. This position also leads and develops processes for securing outpatient authorizations. The team works closely with clinic offices and provides and obtains accurate, timely authorizations from payors.

Key Accountabilities:

• 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.

• 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 them.

Required:

• Five (5) years of management experience in care management & care coordination setting and/or clinical experience.
• Bachelor Degree

Desired:

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

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