Utilization Management Director jobs in Louisiana

Utilization Management Director leads and directs the utilization review staff and function for a healthcare facility. Determines policies and procedures that incorporate best practices and ensure effective utilization reviews. Being a Utilization Management Director manages and monitors both concurrent reviews to ensure that the patient is getting the right care in a timely and cost-effective way and retrospective reviews after treatment has been completed. Provides analysis and reports of significant utilization trends, patterns, and impacts to resources. Additionally, Utilization Management Director consults with physicians and other professionals to develop improved utilization of effective and appropriate services. Requires a master's degree. Typically reports to top management. Typically requires Registered Nurse(RN). The Utilization Management Director manages a departmental sub-function within a broader departmental function. Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure. Deep knowledge of the managed sub-function and solid knowledge of the overall departmental function. To be a Utilization Management Director typically requires 5+ years of managerial experience. (Copyright 2024 Salary.com)

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Registered Nurse - Utilization Management
  • ERP International
  • Barksdale, LA OTHER
  • Overview

    ERP International is seeking a Utilization Management Registered Nurse (RN) for a full-time position supporting the 2d Medical Group, Barksdale AFB, LA 

     

    Be the Best!  Join our team of exceptional health care professionals across the nation. Come discover the immense pride and job satisfaction ERP Employees experience in providing care for our Military Members, their Families and Retired Military Veterans!  ERP International is honored to have been named one of The Washington Post’s 2023 Top Workplaces!

    * Excellent Compensation & Exceptional Comprehensive Benefits!* Paid Vacation, Paid Sick Time, Plus 11 Paid Federal Holidays! 

    * Medical/Dental/Vision, STD/LTD/Life, Health Savings Account available, and more!* Annual CME Stipend and License/Certification Reimbursement!

    * Matching 401K!

     

    About ERP International, LLC: ERP is a nationally respected provider of health, science, and technology solutions supporting clients in the government and commercial sectors. We provide comprehensive enterprise information technology, strategic sourcing, and management solutions to DoD and federal civilian agencies in 40 states. Founded in 2006, ERP is headquartered in Laurel, MD and maintains satellite offices in Montgomery, AL and San Antonio, TX - plus project locations nationwide. ERP is an Equal Opportunity Employer - Disability and Veteran.

    Responsibilities

    Schedule:

    Monday - Friday, 9 hours between 7:00am and 5:00pm, with a one-hour lunch

    No Weekends or Holidays

     

    Duties: The duties include, but are not limited to the following;

    • Assist with orientation and training of other Medical Management staff and assist inproviding, assessing, and improving a wide variety of customer service relations. AssistsMTF officials to ensure Unit Effectiveness Inspection standards are met at the operationallevel.
    • Assists in the development and implementation of a comprehensive UtilizationManagement plan/program for beneficiaries within MTF’s goals and objectives. Thisplan is based on using the 12-step approach as described in the DoD MedicalManagement Guide.
    • Establish procedures for conducting reviews, including identification of types ofhealthcare services for which preauthorization or concurrent review will be required.Reviews previous and present medical care practices as needed for patterns, trends, orincidents of under or over utilization of hospital resources incidental to medical careprovided to beneficiaries.
    • Plans and performs reviews IAW established indicators and guidelines to providequality cost-effective care. Ensures identified patient needs are addressed promptly withappropriate decisions. Provides timely, descriptive feedback regarding utilization reviewissues. Use the same generally accepted standards, norms, and criteria to review thequality, completeness, and adequacy of healthcare provided within the MTF, as well asits necessity, appropriateness, and reasonableness.
    • Adhere to the established standardized DCS appeal process for resolvingbeneficiaries’ request for reconsideration of MTF denials of care based on medical necessity determinations in accordance with References (e) and (o). After following the directed methodology for appeals, the MTF will also adhere to its respective Service or joint commands’ process for intermediate notification, if any, prior to progressing from the internal to external level of appeals.
    • Adhere to the MHS and Military Department’s or Joint Medical Commands’ referral management policies to manage internal and external referrals. Incorporate UM strategies as part of the referral management center’s routine processes. Ensure processes monitor, manage, and optimize demand or capacity (access).
    • Collaborate with the PCMH team to develop performance measures and processes for clinically important conditions, as determined by the PCMH teams and MTF leadership. These clinically important conditions should include but may not be limited to high -cost, high-volume, or problem-prone diagnoses, procedures, services, and beneficiaries that utilize healthcare at higher rates than average and who may benefit from intervention and more intense care coordination. Performs data/metric collection. Analyzes data and prepares reports to describe resource utilization patterns. Briefs applicable data/slides to provider staff, executive staff, newcomers, as appropriate. Identifies areas requiring intensive management or areas for improvement.
    • Maintains reports on which cases have been denied or received reduced third party payments and reports provider profiles to the MTF management for corrective action.
    • Serves as a liaison with higher headquarters, TRICARE Regional Office, MTF national accreditation organization, professional organizations, and community health care facilities concerning Utilization Management.
    • Participates in in-services and continuing education programs. Briefs applicable data/slides to provider staff, executive staff, newcomers, as appropriate.
    • Establishes and maintains good interpersonal relationships with co-workers, families, peers, and other health team members. Submits all concerns through Utilization Management Director; be able to identify, analyze and make recommendations to resolve problems and situations regarding referrals. Ensure coordination and communication among all MM staff, including clinical and business personnel, to assure efficient, effective, quality care and services.
    • Be productive and perform with minimal oversight and direction. Be able to independently identify, plan, and carry out projects with consideration for the goals and objectives of the TRICARE Utilization Management Element. Develops detailed procedures and guidelines to supplement established administrative regulations and program guidance. Recommendations are based upon analysis of work observations, review of procedures, and application of guidelines.

     

    Qualifications

    Minimum Qualifications:

    * Education: Minimum BSN from an accredited college or university* Experience: Six years of clinical nursing experience is required. One year of previousexperience in Utilization Management is required. Full time employment in a nursingfield within the last 36 months is mandatory.  Knowledge, skills and computer literacy to interpret and apply medical carecriteria, such as InterQual or Milliman Ambulatory Care Guidelines.Must possess experience in performing prospective, concurrent, and retrospectivereviews to justify medical necessity for medical care to aid in collection and recoveryfrom multiple insurance carriers. Review process includes Direct Care and Purchase CareSystem referrals, ward rounds for clinical data collection, contacting providers to informthem of dollars lost for missing documentation, and providing documentation for appealsresolution.  Possesses working knowledge of Ambulatory Procedure Grouping (APGs),Diagnostic Related Grouping (DRGs), International Classification of Diseases-Version 9(ICD), and Current Procedural Terminology-Version 4 (CPT-4) coding.

    * Licensure: Current, full, active, and unrestricted RN license from any state.

    * Life Support Certifications: AHA or ARC BLS Certification * Security:Must possess ability to pass a Government background check/security clearance.

  • 21 Days Ago

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Utilization Review Analyst - Utilization Management - Full Time
  • Woman's Hospital
  • Baton Rouge, LA FULL_TIME
  • Job Details Description The UM Analyst analyzes patient records daily to determine the appropriateness of admission, level of care, continued stay and discharge. Abstracts variances to standard pathwa...
  • 28 Days Ago

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Utilization Review Analyst - Utilization Management - Full Time
  • Womans Hospital
  • Baton Rouge, LA FULL_TIME
  • The UM Analyst analyzes patient records daily to determine the appropriateness of admission, level of care, continued stay and discharge. Abstracts variances to standard pathway process. Provides ongo...
  • 28 Days Ago

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DIRECTOR - UTILIZATION REVIEW / MGMT
  • Universal Health Services, Inc.
  • Harahan, LA FULL_TIME
  • Responsibilities River Oaks Hospital, located in metropolitan New Orleans, Louisiana, is a private psychiatric facility for adults, adolescents and children. Since 1970, River Oaks has established a t...
  • 1 Month Ago

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DIRECTOR - UTILIZATION REVIEW / MGMT
  • UHS
  • HARAHAN, LA FULL_TIME
  • Responsibilities River Oaks Hospital, located in metropolitan New Orleans, Louisiana, is a private psychiatric facility for adults, adolescents and children. Since 1970, River Oaks has established a t...
  • Just Posted

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DIRECTOR - UTILIZATION REVIEW / MGMT
  • River Oaks Hospital
  • Harahan, LA FULL_TIME
  • Responsibilities: River Oaks Hospital, located in metropolitan New Orleans, Louisiana, is a private psychiatric facility for adults, adolescents and children. Since 1970, River Oaks has established a ...
  • Just Posted

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Managing Director
  • SpartaCraft
  • Connelly Springs, NC
  • Job Description Job Description SpartaCraft, a contract wood products and finishing company in Connelly Springs, NC is l...
  • 3/28/2024 12:00:00 AM

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Health Information Management Director
  • Clinical Management Consultants
  • Waterflow, NM
  • Calling all Health Information Management professionals looking to advance their career by joining an award winning hosp...
  • 3/28/2024 12:00:00 AM

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Managing Director
  • Chapman Associates, Inc.
  • Chapman Associates is a Mergers & Acquisitions association focused on middle-market strategic acquisitions on the buy an...
  • 3/28/2024 12:00:00 AM

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Case Management Director
  • Clinical Management Consultants
  • Plainview, TX
  • An award winning medical center is searching for a strong, experienced Case Management Director. Our team is excited to ...
  • 3/25/2024 12:00:00 AM

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Managing Director / Senior Managing Director - Debt Advisory
  • Oberon Securities, LLC
  • New York, NY
  • Oberon Securities, based in New York City, is seeking experienced Managing Directors with expertise raising asset, cash ...
  • 3/25/2024 12:00:00 AM

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Managing Director Relationship Manager-MMB
  • First Citizens Bank
  • Santa Monica, CA
  • Overview: First Citizens Middle Market Banking delivers a range of financial solutions to midsize clients through a rela...
  • 3/25/2024 12:00:00 AM

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Managing Director
  • Transamerica Premier Life Insurance Company
  • Nashville, TN
  • The Managing Director is responsible for growing the business of the District Office by developing new quality sales, co...
  • 3/25/2024 12:00:00 AM

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Managing Director
  • Artech L.L.C.
  • Fremont, CA
  • Artech is currently looking to hire an experienced Managing Director to join our expanding team in Fremont, CA (Hybrid)....
  • 3/25/2024 12:00:00 AM

Louisiana is bordered to the west by Texas; to the north by Arkansas; to the east by Mississippi; and to the south by the Gulf of Mexico. The state may properly be divided into two parts, the uplands of the north, and the alluvial along the coast. The alluvial region includes low swamp lands, coastal marshlands and beaches, and barrier islands that cover about 20,000 square miles (52,000 km2). This area lies principally along the Gulf of Mexico and the Mississippi River, which traverses the state from north to south for a distance of about 600 mi (970 km)) and empties into the Gulf of Mexico; ...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Utilization Management Director jobs
$120,076 to $162,365

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