Utilization Review Rn Jobs in Flowery Branch, GA

RN Executive Director of Utilization Management and CDI
Gainesville, GA

As the Executive Director of Utilization Management/CDI, you'll lead efforts to connect clinical excellence with financial strength. In this role, you'll oversee Utilization Management and Clinical Documentation Integrity to ensure accurate documentation, appropriate resource use, and strong reimbursement outcomes. You'll work closely with physicians, hospital leadership, and cross-functional teams to reduce denials, improve Case Mix Index (CMI), and support quality patient care. If you're a collaborative leader who thrives on driving both clinical and operational success, this is the opportunity to make a lasting impact.

Qualifications:

• Registered Nurse license required
• Bachelor's Degree in Nursing required
• Director of Utilization Management and CDI experience combined in an Acute Hospital Setting, with progressive Revenue Cycle leadership experience required
• Utilization Management specific certification preferred (CCM, ACM, CPUR) preferred
  CDI/coding certification preferred
• Master's Degree in Nursing or other health related field preferred

Responsibilities:

• Oversees Utilization Management working closely with Case Management and other members of the interdisciplinary team to ensure effective collaboration for length of stay and throughput
• Communicate with and educate physicians and other key stake holders regarding Utilization Review policies, practices, and procedures to ensure safe, effective services, along with appropriate transitions of care
• Assesses departmental workload to determine appropriate staff allocations to ensure productivity standards are being met consistently
• Oversee day-to-day operations of the Utilization Management Department, ensuring compliance with payer requirements and regulatory standards
• Oversee and manage the CDI department to ensure ongoing accuracy, completeness, and specificity of clinical documentation
• Work closely with case management, managed care, and patient financial services to streamline utilization review and enhance hospital financial performance
• Monitor and analyze key performance indicators (KPIs), financial goals, and length of stay (LOS) metrics to drive performance improvements
• Recruit, train, and manage a high-performing CDI and UM team, ensuring operational alignment with hospital objectives
• Manage departmental budgets, ensuring financial responsibility and resource allocation
• Develop and implement performance metrics to evaluate team effectiveness and drive continuous improvement
• Foster strong relationships with internal and external stakeholders, including hospital executives, physicians, and payers
• Provide data-driven insights and strategic recommendations to hospital leadership regarding CDI and UM performance
• Act as the operational leader for process improvement initiatives related to documentation, utilization management, and revenue cycle optimization
• Work closely with Physician Advisors to develop and revise policies and procedures related to clinical status determination, medical necessity, clinical documentation, denials and appeals, and physician education
• Provides education to operational leaders, staff and Physicians on the importance of the
• Clinical Documentation Improvement Program (CDIP), and works cooperatively with them to ensure that improved documentation is seen as part of the strategic mission of the Organization
• Facilitate modifications to clinical documentation through extensive concurrent interactions with Physicians, nursing staff, case managers, and coding team to ensure that appropriate reimbursement and severity of illness (SOI) is captured
• Coordinates, comply with and share data reflecting the activity associated with the Documentation Program on an on-going basis highlighting key performance indicators
• Act as operational leader for Clinical Documentation Improvement Initiative with The Advisory Board to achieve "best practice" across the System, partnering with the medical staff, including Hospital employed Physicians and independent Physicians providers in the community
• Review daily, weekly and monthly reports to monitor and analyze performance of UM and CDI departments, assess data against KPI standards and goals, and identify trends to make adjustments as indicated
• Works closely with physicians and staff to provide and monitor clinical/financial data for the purpose of improving hospital/physician performance and anticipating payer and managed care demands
• Actively participates as the operational leader for UM and CDI in committees including but not limited to MRUR; Compliance; Policy and Procedures; and Quality
• Identifies and maintains good relationships with other departments such as Managed Care,
• Patient Financial Services, Patient Access, and others so to facilitate the utilization review processes and to provide continuity of care

How to Apply:

Interested candidates, please submit your resume to Michelle Boeckmann at Michelle@HCRecruiter.com. Visit www.HealthcareRecruitmentPartners.com/careers for more details and additional opportunities. Feel free to share these contact details with anyone interested in Case Management or Utilization Management roles.

Contact: Michelle Boeckmann | President, Case Management Recruitment
Direct Dial: 615-465-0292
Michelle@HCRecruiter.com | www.HealthcareRecruitmentPartners.com/careers

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