Director Patient Access And Utilization Review

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Work Shift Day
Work Day(s) Monday-Friday
Shift Start Time 8:30 AM
Shift End Time 5:30 PM
Worker Sub-Type Regular
Children’s is one of the nation’s leading children’s hospitals. No matter the role, every member of our team is an essential part of our mission to make kids better today and healthier tomorrow. We’re committed to putting you first, and that commitment is at the heart of our company culture: People first. Children always. Find your next career opportunity and make a difference doing what you love at Children’s.
The Director, Patient Access and Utilization Review provides operational and strategic leadership for a large team responsible for main admitting and Emergency Department registration at our three hospitals. The Director also oversees centralized teams responsible for insurance verification and authorization of scheduled hospital services, as well as for the enrollment of patients in Medicaid and other appropriate coverage programs. The Director also oversees the hospital Utilization Review team responsible for assigning the admission status appropriate for care received as well as obtaining payor authorization for care provided.
Reporting to the Vice President, Revenue Cycle, this leader’s teams work closely with Hospital Clinical Operations, Physicians, Case Management and Health Information Management to capture patient and guarantor information to facilitate care delivery. The Director collaborates with stakeholders throughout Children’s related to Patient Access functions, including scheduling, pre-certification, authorization, insurance enrollment, insurance verification, registration, and financial assistance. Collaborate with Clinical Operations, Patient Accounts, Information Technology, and other stakeholders to ensure department operations support revenue cycle processes related to claim billing, appeals, follow-up and payment posting.
Key Responsibilities
Provide strategic direction and vision to optimize the day-to-day operations of Patient Access and Utilization Management teams for all hospital campuses.
Oversee day to day Patient Access operations for Main and Emergency Department registration for all hospital campuses as well as centralized resources at the Support Center.
Oversee the implementation of Epic and other information systems related to scheduling, pre-arrival insurance verification and authorization, registration, and Medicaid enrollment for all areas of responsibility and consults with other areas using these systems and related workflows.
Provide oversight and promotion of quality of care, appropriateness of patient care, resource utilization management, and the development of policies and standards for the Utilization Management Program as co-chair of UM Committee.
Collaborate with the UM Medical Directors to secure appropriate authorizations for inpatient and observation stays as well as to develop and execute a Utilization Management Plan for all hospital campuses, consistent with state and federal regulations.
Manage human and system resources to facilitate appropriate clinical care as well as successful claim submission including monitoring of data collection accuracy and appropriate insurance verification, pre-certification, and authorization.
Monitor work quality, staff productivity and performance results in collaboration with IT, Performance Analytics and Revenue Cycle stakeholders.
Oversee the identification of funding sources for uninsured and under-insured patients who present for treatment by maintaining current knowledge of state, federal, and non-governmental funding as well as developing professional partnerships with area resources.
Oversee the implementation of Children's system-wide Financial Assistance and Charity policies and processes to ensure compliance with state and federal regulations as well as to support the system’s mission.
Monitor denials received related to Patient Access workflows and processes throughout the system and develop action plans to address recurring issues in collaboration with clinical and physician leaders.
Develop, implement, and update policies related to patient and guarantor data collection, insurance verification, authorization and other patient access workflows areas assigned in collaboration with peers and stakeholders in Patient Accounting, Case Management, HIM, Coding, and IS&T.
Identifies and addresses educational requirements for system staff involved in patient access processes system-wide based on the technical and operational requirements of the system and dynamic and complex payor environment, state and federal regulations and accreditation requirements.
Evaluate and recommend system policies, training and system configuration related to patient access related processes and workflows in collaboration with peers and stakeholders throughout the system and participation in appropriate committees and work groups.
Mentor team members to encourage personal and professional growth. Encourages ongoing skill development by providing opportunities for continued education.
Required Experience
Minimum five years management experience in patient access, hospital operations or health care Revenue Cycle management experience in a multi hospital health system.
Demonstrated experience in developing processes, procedures and policies that positively impact departmental and health system results.
Educational Requirements
Bachelor’s Degree in a medical or business-related field is required. MBA or MHA degree is preferred.
Knowledge, Skills, and Abilities
Exceptional leadership skills, including the ability to engage stakeholders, motivate teams and successfully resolve conflicts.
Understanding of key health care revenue cycle compliance guidelines, regulations, and accreditation, including those related to HIPAA, Medicaid, EMTALA, PCI and the Joint Commission.
Working knowledge of insurance industry pre-certification, authorization, and utilization management criteria such as InterQual and Milliman.
Ability to identify, develop, and implement strategic process improvements to support organizational goal attainment.
Ability to partner constructively with health system service line and physician leaders, as well as other healthcare practitioners.
Proficient in Excel, Word, and PowerPoint.
Personal Characteristics
Exceptional verbal and written communications; strong business acumen; interpersonal skills and strong collaborative nature; team player; consensus builder; and persuasive presenter.
History of building and fostering trusting, sustainable relationships, both internally and externally. Able to collaborate and partner with other subject matter experts and departmental leaders.
Active listener. Seek to understand the point of view and needs of stakeholders and executives.
Strong negotiation skills. Able to develop win/win solutions for Children’s and external partners.
Ability to balance emotional intelligence and business insights when communicating with stakeholders. Possess the depth of experience to know when to persuade vs. negotiate.
High level of service orientation—responsive to the needs of key stakeholders.
Strong track record of developing and engaging a team. Demonstrated ability to build trust, mentor, conduct regular check-ins, use situational leadership, etc. Approachable and enthusiastic leader who is accessible and visible to the team on a regular basis.
Self-motivated and directed individual who pays attention to the details and doesn’t cut corners. Ability to multi-task and prioritize activities in a high energy setting.
An individual of the highest integrity with high levels of energy, maturity, and humbleness.
Preferred Qualifications
HFMA or NAHAM certification is preferred.
Primary Location Address 1575 Northeast Expy NE
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