The position provides comprehensive assessment, coordination, implementation and reporting of complex clinical data. This position audits medical records on behalf of hospital clients for denials review, defense audits, disallowed charges and ongoing insurance reviews. Develops, implements, monitors and documents the utilization of resources and progress of the patient throughout the continuum of acute care. Advocates and facilitates options and services to meet the patient`s health care needs. Assists the Manager,Case Management, with the daily operational activities by monitoring quality and effectiveness of workflow, problem resolution and troubleshooting issues, and processes to ensure optimum efficiency and compliance with all regulatory licensing requirements. This position may supervise Utilization Management staff on an adhoc basis as directed by the Manager,Case Management. This position works independently receiving supervision of work activities from the Manager,Case Mgmt.

• Leadership
  
  Provides guidance, mentoring, and direction as appropriate for ongoing staff development.
  
  With the Medical Director of Utilization Management and the Care Management leadership team plans, recommends, organizes and implements approved protocols, policies, and guidelines for the Utilization Management Program and supports overall organizational values and mission.
  
  Participates in hospital and departmental operational initiatives to evaluate and improve reimbursement, denials, level of care and goal length of stay.
  
  Coordinates work activities of assigned staff to ensure achievement of established goals, objectives, and outcomes.
  
  Collaborates with Lead Case Manager, Case Management Manager, Care Management Director and Utilization Medical Director.
  
  Leads employees through ongoing goal setting, training and performance feedback.
  
  Evaluates performance of Utilization Management technician and assists in completing performance appraisals.
  
  Provides team leadership, demonstrates strong, consistent clear communication and serves as central point of information informing all team members.
  
  Cultivates and maintains effective interaction/communication with members of the interdisciplinary team, Case Manager/Utilization Teams to drive the care coordination process and to facilitate continuity of patient care.
• Utilization Management
  
  Manages Utilization Management processes to achieve effective management of goal length of stay and resource utilization in a manner that promotes sound financial stewardship as well as patient-family advocacy.
  
  Completes ongoing insurance reviews utilizing MCG criteria to identify needs related to admission and continued stay.
  
  Leveraging MCG evidence-based guidelines, coordinates, development and implementation of a comprehensive plan in collaboration with the Case Management Team.
  
  Proactively collaborates with members of the interdisciplinary clinical care team to define and document a clear and comprehensive treatment plan. Identifies and facilitates resolution of variances in the plan of care that may impact goal length of stay.
  
  Facilitates and provides on-going communication with Utilization Management/Care Management Teams, escalates unresolved barriers to timely discharge to Case Manager, Manager of Case Management and Utilization Management Medical Director, as per department protocols.
  
  Reviews and analyzes denials received in the Utilization Management Department and communicates to Case Manager, Manager of Case Management and Utilization Management Medical Director, as per department protocols.
  
  Cultivates and maintains effective interaction/communication with members of the interdisciplinary team.
  
  Reviews the patient reports daily for appropriate level of care, goal length of stay as per MCG criteria and communicates with assigned unit Case Manager.
  
  Assesses each patients status as appropriate to patient needs. Ensures timeliness of care and identifies barriers to transition of care or discharge.
  
  Communicates with Utilization Management Leadership denials requiring a physician to physician conversation.
  
  Attends insurance meetings with Utilization Management Medical Director and Care Management leadership as needed.
  
  Attends Denial Committee meetings with Hospital Revenue Cycle/ Physician Revenue Cycle as needed.
  Attends Utilization Management meetings with Utilization Management Medical Director and Care Management leadership as needed.
• Develops collaborative health care team
  
  Collaborates with interdisciplinary team on level of care, goal length of stay, identified barriers, and other issues that may impact reimbursement.
  
  Establishes a collaborative relationship with Hospital Revenue Cycle management and staff, and community providers. Mentors internal members of the health care team on utilization management.
  
  Identifies from review of documentation opportunities for ongoing education with physicians and the health care team.
  
  This position performs onsite job duties and responsibilities at Phoenix Children's, and is viewed as an accessible member of the health care team.
  
  Participates in monthly department process improvement meetings.
• Regulatory Responsibilities
  
  Monitors performance of Utilization Management process in accordance with all state mandate regulations, understands and focuses on key performance indicators and promptly reports potential denials to Case Management Team.
  
  Working knowledge of DRG payment methodology and ICD9/ICD-10 coding system.
• Financial Accountability
  
  Utilizes MCG criteria to determine admission status, level of care, goal length of stay and continued provision of services.
  
  Communicates with payers to resolve potential denials.
  
  Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct ongoing insurance reviews.
  
  Manages optimal outcomes to promote high quality of care in the most cost-effective manner and appropriate setting.
  
  Participates in various aspects of the hospital revenue- cycle by documenting in patient and financial account systems any avoidable days, extended length of stay, authorizations, request of next review due, denials and rescinded days for medical necessity.
  
  Consults with social services and other resources as needs or problems are identified.
  
  Completes monthly documentation and financial audits as requested by department manager and director.
  
  Provides ongoing management of denial and appeal with Hospital Revenue Cycle Department and the Nurse Auditor. Reports trends to Care Management and Utilization Leadership.
  
  Manages in collaboration with Case Managers denials attributed to medical necessity, appropriate level of care or extended length of stay. Communicates and documents potential denials and non-certified days in EMR and financial applications.
• Provides excellent customer service
  
  Establishes a collaborative relationship with interdisciplinary team, community providers and Hospital Revenue Cycle management and staff.
  
  Provides excellent service routinely in interactions with all customers, i.e. coworkers, patients, visitors, physicians, volunteers, etc.
  
  Responds to emails within 24 hours.
  
  Clear communication skills with all internal and external customers.
• Performs miscellaneous job related duties as requested.
  

To advance hope, healing and the best healthcare for children and their families

Phoenix Children's will be the leading pediatric health system in the Southwest, nationally recognized for exceptional care, innovative research and advanced medical education.

We realize this vision by:

• Offering the most comprehensive care across ages, communities and specialties
• Investing in innovative research, including emerging treatments, tools and technologies
• Advancing education and training to shape the next generation of clinical leaders
• Advocating for the health and well-being of children and families

• We place children and families at the center of all we do
• We deliver exceptional care, every day and in every way
• We collaborate with colleagues, partners and communities to amplify our impact
• We set the standards of pediatric healthcare today, and innovate for the future
• We are accountable for making the highest quality care accessible and affordable