System Director of Utilization Review

Pay Range:$75.26 - $105.59

SEARHC is a non-profit health consortium which serves the health interests of the residents of Southeast Alaska. We see our employees as our strongest assets. It is our priority to further their development and our organization by aiding in their professional advancement.

Working at SEARHC is more than a job, it’s a fulfilling career. We offer generous benefits, including retirement, paid time off, paid parental leave, health, dental, and vision benefits, life insurance and long and short-term disability, and more.

Shift Details

• M-F 8-5

Key Essential Functions and Accountabilities of the Job

• Responsible for directing a system-wide care coordination process, including Utilization Review and Social Services, in multiple locations.

• Must be able to understand and manipulate advanced systems and work with and synthesize large relational data sets, providing descriptive/predictive/prescriptive analytics to support operational behavior modification.

• Meet and exceed department service, operational and financial goals, provide analysis, identification of variances and develop action plans to achieve established goals. Report unit performance to internal stakeholders as required.

• This position works intensively with advanced systems to track and trend denials, builds models for documentation improvement plans, and coordinates with all areas and levels of Southeast Alaska Regional Health Consortium (“SEARHC”) Hospitals.

• Work closely with revenue cycle and other finance staff to maximize revenues while maintaining compliance with regulations affecting utilization management. The position requires close interaction with and knowledge of the Medicare and Medicaid programs and other third-party payers.

• This position works closely with the provider community to improve clinical documentation and with administration to ensure appropriate hospital resource use. Care coordination includes the internal collaboration with the SEARHC Primary Care Clinics and Long-Term Care facilities. External collaboration includes tertiary care, assisted living, and psychiatric facilities.

• Direct the Care Coordination Department and ensure safe, efficient, and effective utilization of hospital facilities and services.

• Maintain compliance with all regulations.

• Participate in the development and implementation of departmental policies and procedures, and monitor/ensure compliance and consistency.

• Review and revise workflows and procedures to ensure maximization of resources and excellence in customer service.

• Chair the Utilization Review Committee. Coordinate and attend all Quarterly Utilization Review meetings and provide information and data relative to the review process and any identified problems.

• Works collaboratively with Physician Advisor and provider teams to ensure the appropriateness and necessity of an individual’s admission to or continued stay in hospital.

• Monitor quality measures, collecting and analyzing data to improve utilization of services and the effectiveness and appropriateness of support services.

• Oversee and support the psychiatric emergency service clinicians who assist the Emergency and Inpatient departments in patient assessments and recommendations to care team.

• Ensure timely and appropriate maintenance of records, with documentation of services provided and progress consistent with the care plan.

Additional Details:

Education, Certifications, and Licenses Required

• Bachelor’s degree from an accredited school required.

• Higher level of education preferred.

• Current full, unrestricted Registered Nursing license in Alaska or other U.S. state required.  Direct Hire must have applied for an Alaska nursing license before start date.  Agency staff must have an active Alaska license OR

• Licensed Vocational Nurse in Alaska or other U.S. state required.  Direct Hire must have applied for an Alaska nursing license before start date.  Agency staff must have an active Alaska license OR

• Masters or Doctoral level clinical degree in social work, psychology, health information management or other healthcare related field.

• High school diploma or equivalent required.

• Clinical Competency required within 3 months of hire and every three years

• Manager Competency required within 3 months of hire and every three years

Experience Required

• Prior experience in the utilization and review function required.

• Previous management experience in supervision or administration required. 

• Prior experience working in a Critical Access Hospital model preferred. 

• Five years of clinical experience preferred.

• Prior experience in Performance Improvement preferred.

Knowledge of

• Knowledge of health care service delivery systems and third-party reimbursement; knowledge of managed care environment. 

• Solid understanding of healthcare, federal, and state regulations. 

• Understanding of admission and discharge functions. 

• Familiarity with medical terminology, diagnostic terms, and treatment modalities. 

Skills in

• Strong interpersonal, organizational, evaluative, and time management skills. 

• Policy interpretation skills; familiarity with applicable standards and regulations. 

• Provider communication and behavior change can be challenging; this individual must be an expert communicator and change agent.

• Responsiveness to deadlines; assertiveness, persistence, and persuasiveness. 

Ability to

• Ability to apply and interpret admission and continued stay criteria.

• Ability to organize tasks related to the accomplishment of hospital goals and objectives. 

• Ability to work in a professional manner with physicians, outside agencies, and support staff. 

• Ability to travel to multiple locations. Travel is by jet, small aircraft, or ferry.

Physical Demands:

• While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand; walk; sit; use hands to finger, handle or feel and reach with hands and arms.

• The employee is occasionally required to climb or balance; stoop, kneel, crouch or crawl. The employee must lift and/or move 50 lbs.

Position Information:

Work Shift:Exempt

If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!