Position will work 40 hours/week between the hours of 7:30am-4pm, no weekends/holidays
SUMMARY: LG Health/Penn Medicine is currently seeking a Supervisor – Utilization Management. Under the direction of the Manager, Utilization Management (UM) and Financial Clearance Center the Supervisor is responsible for the day to day operations of the Care Management Admission Team, and Denials Team. Provides direction to assure denied claims are appealed in a timely manner, trends in denials are identified and forwarded to the appropriate department for follow up. Researches and coordinates completion of patient records required to appeal medical necessity denials for payment of claims. Identifies area for documentation and/or process improvement and promotes pro-active documentation compliance for reimbursement. Demonstrates ability to adapt to ongoing changes within the health insurance industry in order to effect and implement positive changes for the financial growth of Lancaster General Health. Keeps well informed of regulatory requirements/changes concerning MA, Medicare and third party payors.
Supervises operational activities of the Care Management Admission Team and Denials Team using metrics to measure and monitor performance, team standard operating procedures (SOP), and compliance.
Identifies areas for improvement of existing operational policies and SOPs utilizing LEAN methodology and follows through with implementation of changes.
Supervises staff hiring, work allocation, and scheduling, training and professional development, performance management and related supervisory activities.
Supervises all clinical activities related to patient care, establishing standards of care and documentation of such.
Provides clinical guidance and assesses employee competency and maintains ongoing record of staffs’ performance and documentation including solicitation of input from others and completes department performance review processes.
Assists the Manager in managing the department budget. Maintains procedures and data quality monitoring plans and prepares reports.
Monitors data quality and productivity. Works with the Manager to set quality and productivity standards, reports, and takes corrective action where appropriate.
Participates in the building of systems and processes to most effectively manage healthcare consumer needs and medical cost management (information systems, quality and utilization management).
Current RN license, issued by the PA Board of Nursing.
Two (2) years of leadership experience in nursing or related healthcare position.
Three (3) years of experience with utilization management .
Three (3) years of experience in acute care or health insurance environment.
Three (3) years of experience working with physicians, staff and executive staff.
Bachelor’s degree in Nursing (BSN) or a related health care degree is preferred.
Experience in the applicaton of InterQual or MCG is strongly preferred.
About Lancaster General Health/Penn Medicine
Lancaster General Health (LG Health), a member of the University of Pennsylvania Health System (Penn Medicine), is a 663-licensed bed not-for-profit health system with a comprehensive network of care encompassing Lancaster General Hospital (LGH), Women & Babies Hospital and the Lancaster Rehabilitation Hospital (in partnership with Kindred Healthcare). Our membership in Penn Medicine brings together the strengths of a world-renowned, not-for-profit academic medical center and a nationally recognized, not-for-profit community healthcare system.
Outpatient services are provided at the Downtown and Suburban Pavilions, along with additional outpatient facilities and Express and Urgent Care locations throughout the region. Lancaster General Health Physicians is a network of more than 300 primary-care and specialty physicians, at more than 40 offices throughout the region. Pennsylvania College of Health Sciences is a private, co-educational, Middle States-accredited four-year college offering a variety of associate and baccalaureate degree and certification programs in healthcare.
LGH has been designated a Magnet hospital for nursing excellence four times. It has been recognized ...regionally and nationally for clinical excellence and patient safety; and ranked nationally by U.S. News & World Report as one of the nation’s best hospitals in 2016-17.