Manages the daily operations for the Insurance Verification (IV) and Utilization Management (UM) team, including staffing, workflow processes, reporting, complaint resolution, employee leadership and on-going staff education. Accountable for creating a culture of compliance, ethics and integrity. Maintains and shares with team insurance and payer standards and changes.
1. Determines staff qualifications and competency: recruits, selects, hires, trains, orients, mentors and rewards.
2. Supervises and develops an effective staff: providing effective communication, leadership, guidance and resources. Directs in-service and continuing education activities for staff. Monitors staff safety compliance and use of Personal Protective Equipment (PPE), as needed.
3. Evaluates staff performance regularly and determines merit increases, promotions and disciplinary actions.
4. Responsible for verifying that insurance, referrals, pre-notification, precertification, authorization, medical terminology and coding practices are followed for all ancillary procedures.
5. Monitor local patient UM workflow to assure timely authorizations for all scheduled procedures. Continually assess UM workflow for improvement opportunities.
6. Accountable for IV/UM compliance to regulatory and insurance standards.
7. Measures turnaround time (arrival to completion) of IV requests. Establishes and maintains turnaround time expectations for IV to support NJH goals.
8. Manages Program patient utilization management team. Monitors workflow to assure timely authorizations for all Program Services scheduled. Maintains strong communication with Manager, Program Patient Services.
9. Accountable for the coordination of the administrative aspects of Infusion Centers including insurance verification, third party authorization, pharmacy coordination, Drug Map Program and the completion of the standard schedule in an appropriate manner for Oncology and Infusion patients through oversight of Infusion Coordinator.
10. Provides coaching, leadership and direction to a team who are responsible for providing IV and UM services. Establishes and maintains on-going insurance education for IV and UM staff.
11. Completes quality assurance review of staff work. Meets with staff monthly to review performance related to quality and quantity.
12. Generates and presents key performance indicator reports to Director on a weekly and monthly basis.
13. Reviews claim denials monthly for verification and authorization errors. Report monthly findings to Director.
14. Serves as a key member of patient care team and proposes procedural and system changes when appropriate.
15. Works closely with other Administrative Services leaders and Patient Financial Services.
16. Develops written policy and procedural manual for IV/UM team. Responsible for ensuring IV/UM team adheres to institutional and Departmental polies.
17. Performs all other duties as assigned.
1. Performs, as directed, safety compliance and uses Personal Protective Equipment (PPE), as needed.
2. Participates in Quality Assessment (QA) and Quality Improvement (QI) programs, as directed.
3. Ensures compliance with The Joint Commission and all other Federal, State and Regulatory Agencies.
4. Responds promptly and sincerely to customer's needs, requests and concerns via all communication forms using easily understood language and refraining from using inappropriate language and non-verbal gestures.
5. Maintains positive working relationships as a team player through problem solving issues, speaking positively about others, listening attentively and observing the Patient Bill of Rights and Confidentiality.
6. Increases customer service knowledge, skill and ability by participating in department and institution-wide specific programs.
7. Incorporates National Jewish's identity (Science Transforming Life®) into daily functions. Speaks positively about the institution, provides customers with prompt service, maintains a clean and safe working environment, dresses appropriately based upon National Jewish safety standards, and departmental policies and wears an ID badge visibly.
Knowledge and Skills
Incumbent must be proficient in Microsoft Office Suite applications, including Outlook, Excel, and Word, and other business applications. Effective written and oral communications skills and effective organization abilities are required. Knowledge of medical terminology and procedures is required. Incumbent must have the ability to handle multiple projects at once. Capacity to establish and maintain constructive business relationships with internal and external customers while maintaining integrity and confidentiality. Incumbent must be a positive, professional team player, able to manage project time constraints and work with little supervision.
Bachelor's degree in related field is required, (healthcare or business administration preferred).
Certification and Licensure
A minimum of five (5) years of recent and related experience in health care with insurance verification, precertification or utilization management required. A minimum of three (3) years recent management or supervisory experience required.
- or - Any equivalent combination of Education and/or Experience
Position is an office environment. Frequent requirements may include: sitting for extended periods, entering and manipulating data on a workstation computer and participating in team/executive meetings. Approximately 75% of daily responsibilities will be working both one-on-one and in teams with other personnel and extended one-on-one contact in a quiet environment where hearing and listening is paramount. Must possess the ability to communicate by observation, verbal, written and listening; standing; walking; climbing stairs; stooping to remove/replace files; good hand-eye coordination; lifting, pulling, pushing, and upper body twisting while handling supplies and equipment; sitting while completing paperwork; using keyboard for PC and word processing needs. Occasional requirements may include: stand, walk, use hands to manipulate, handle or feel objects, tools, or controls, reach with hands and arms, stoop, kneel, and lift/move up to 25 pounds. Incumbent may be scheduled to work an alternate schedule to accommodate essential business needs routine travel by foot or automobile to alternate work/meeting locations, possibly during inclement weather.
No environmental conditions indicated. Professional office environment with time of each day spent in interaction with management/staff, in addition to planning and working autonomously. Requires teamwork and the ability to handle multiple interruptions; frequently fast-paced; high-pressure; occasionally variable-paced; variable pressure. Personal Protective Equipment (PPE) will be provided to each employee when needed as determined by policy. Utilization of PPE is mandatory. Estimated 1600 employees in the worksite.
Manages 9-11 employees