Director Utilization Management

Baylor St. Lukes Medical Center is an 881-bed quaternary care academic medical center that is a joint venture between Baylor College of Medicine and CHI St. Lukes Health. Located in the Texas Medical Center the hospital is the home of the Texas Heart Institute a cardiovascular research and education institution founded in 1962 by Denton A. Cooley MD. The hospital was the first facility in Texas and the Southwest designated a Magnet hospital for Nursing Excellence by the American Nurses Credentialing Center receiving the award five consecutive times. Baylor St. Lukes also has three community emergency centers offering adult and pediatric care for the Greater Houston area.

The Utilization Management (UM) Director is responsible for the market(s) development implementation evaluation and direction of the Utilization Management Program and staff in support of the CommonSpirit Health Care Coordination model. The Utilization Management department processes authorizations inpatient admission and continued stay reviews retrospective authorizations utilizing standardized criteria to determine medical necessity; reviews and processes concurrent denials that require medical necessity determinations; processes appeals and collaboration with the Division Director Care Coordination the UM Director develops strategies to achieve departmental and CommonSpirit Health goals and objectives. This position directs the UM staff to meet or exceed operational performance standards. The Director oversees development and implementation of UM policies procedures and processes; directs and assists with accreditation activities; efficient management of payer requirements addressing denials effectively and compliance with payer and regulatory requirements and reviews and analyzes UM program outcomes and quality metrics.

Required:

• Bachelors degree in Nursing Health Care Administration or advanced clinical degree.
• Minimum 3 years of clinical case management (Utilization Management Denial Management Care Coordination)
• 5 years of progressively responsible management experience
• Extensive operational experience in managed care; extensive experience in program planning implementation staff
  development and needs assessment
• Comprehensive knowledge of utilization management financial management that includes revenue cycle Medicare Medicaidand commercial admission and review requirements.