DIR UTIL REVIEW & DENIALS MGMT ENTERPRISE QUALITY FROEDTERT HOSPITAL REMOTE
Location: US:WI:MILWAUKEE at our FROEDTERT HOSPITAL facility. This job is REMOTE. FTE: 1.00 Standard Hours: 40.00 Shift: Shift 1 Shift Details: 8:00 am - 4:40 pm, Monday - Friday (can be semi-flexible) Job Summary: The Director of Utilization Review and Clinical Denials Management is responsible for strategic and operational oversight of the Utilization Review (UR) and Clinical Denials Management programs. This high impact leader ensures delivery of medically necessary, cost-effective, and high-quality care through evidence-based UR processes that fully comply with the Centers for Medicare and Medicaid and other payer requirements. The Director drives clinical and operational excellence across the teams responsible for notice of admission, concurrent medical necessity and level of care reviews, UR related patient notices and post discharge reviews including clinical denials/appeals management. Director is accountable for implementing innovative best practices that optimize workflows and integrate AI-enabled decision support to streamline processes and provide real time data for decision making. EXPERIENCE DESCRIPTION: A minimum of five years of experience in an acute care environment with management experience is required. Experience in setting and executing strategies to achieve organizational goals is required. Demonstrated skills in collaborating with others in an academic health system or setting is required. Candidate should be familiar with working within a matrixed organization. EDUCATION DESCRIPTION: Bachelor's Degree in Nursing is required. Master's Degree in a healthcare related clinical discipline or business management is required. SPECIAL SKILLS DESCRIPTION: Working knowledge of financial statistics, data display, and report writing and performance improvement. Proficient in the regulatory and payer requirements for medical necessity, notice of admission and clinical denials management. Proven skills with communication (written, verbal, and presentation). Leadership expertise to develop professional staff and direct the work of the departments. Proficient with Microsoft Office products, electronic databases, and electronic medical record review. Demonstrates exceptional customer service and partnership skills and interacts effectively with staff, providers and other stakeholders. LICENSURE DESCRIPTION: Requires current state of Wisconsin Registered Nurse License or a Multi-state Nursing License from a participating state in the NLC (Nurse Licensure Compact). MCG certification preferred. Compensation, Benefits & Perks at Froedtert Health Pay is expected to be between: (expressed as hourly) $53.51- $90.97. Final compensation is based on experience and will be discussed with you by the recruiter during the interview process. Froedtert Health Offers a variety of perks & benefits to staff, depending on your role you may be eligible for the following:
- Paid time off
- Growth opportunity- Career Pathways & Career Tuition Assistance, CEU opportunities
- Academic Partnership with the Medical College of Wisconsin
- Referral bonuses
- Retirement plan - 403b
- Medical, Dental, Vision, Life Insurance, Short & Long Term Disability, Free Workplace Clinics
- Employee Assistance Programs, Adoption Assistance, Healthy Contributions, Care[redacted], Moving Assistance, Discounts on gym memberships, travel and other work life benefits available
The Froedtert & the Medical College of Wisconsin regional health network is a partnership between Froedtert Health and the Medical College of Wisconsin supporting a shared mission of patient care, innovation, medical research and education. Our health network operates eastern Wisconsin's only academic medical center and adult Level I Trauma center engaged in thousands of clinical trials and studies. The Froedtert & MCW health network, which includes ten hospitals, nearly 2,000 physicians and more than 45 health centers and clinics draw patients from throughout the Midwest and the nation.