SCHEDULE: Full-Time; Monday- Friday; 8:00 a.m.- 4:30 p.m.
The Director of Clinical Resource Management develops and maintains programs for peer review for utilization programs emphasizing concurrent and retrospective analysis of patterns of care. Coordinates all Federal, State, and private peer review activities. Submits the Utilization Management Plan annually to the Utilization Management Committee for review and/or revision and approval. Establishes and submits departmental budget annually. Serves as a resource to the Medical Staff Committees requiring education, edification and/or assistance in their peer review process. Provides for medical staff and indicated hospital staff education in the areas of PPS/DRGs, Medicaid, and other agency requirements for peer review. Attends hospital mandatory in-service education programs. Monitors, analyzes, and reports the impact of the utilization management influences on patterns of care and trends in length of stay. Maintains confidentiality of records, files, and other data relevant to utilization management activities. Coordinates monthly reports of all activities related to the review process for the Utilization Management Committees. Devises, implements, and maintains a program of beneficiary notification on issues of non-coverage under government and commercial health programs. Reviews all denials received by the hospital, regardless of payer source, for appropriateness and where indicated, initiates the appeal process. Implements and maintains pre-admission program consistent with Federal, State, and other fiscal intermediary requirements. Establishes a Discharge Planning Program for patients requiring home health to provide a continuity of care. Supervises and evaluates Resource Management personnel according to pre-established performance standards in a timely manner. Verifies and submits time cards for the department to the Accounting Office biweekly. Assures compliance with CMS conditions of participation for Utilization Review and Discharge Planning. Oversight of throughput activities that assure an efficient care process. Leads the hospitals efforts in transition of care. Serves as the hospital's liaison for post acute partners, assuring an efficient post acute transition process. Provides hospital leadership for the Utilization Review committee, implements action plans as directed and provides data as requested by the committee. Serves as regulatory resource for CMS regulations and commercial payer regulations.
Bachelor's degree in a related field, with a background in nursing. Master's degree is a plus. Five years experience in nursing or related field; minimum of 2 years supervisory experience. Related experience may be substituted for education. Current Alabama Nursing License. Knowledge of Personal Computer systems and computer programs. Ability to establish rapport with hospital personnel and physicians. Moderate demand-high stress related area.