Manager, Utilization Review

Long Tail Health Solutions is a provider advocate, delivering a suite of technology-enabled services which discover and operationalize payer rules and behaviors to improve the visibility, execution, and outcomes of utilization review, case management, and revenue cycle functions. Our mission is to optimize the financial performance and work-lives of healthcare providers by eliminating administrative waste with modern technology applied to long tail problems.

Manages and provides oversight for the concurrent utilization review process and coordination of responses to all requests and regulatory requirements for commercial payors, the Centers for Medicare and Medicaid Services (CMS), audit and denial programs. A 100% remote work force will require very strong communication and remote relationship building skills.

Interviews, hires, orients, trains, develops and evaluates the performance of and, when necessary, disciplines and/or discharges department personnel. Provides direction, as necessary, to staff regarding sensitive and/or complex work, related problems, resolves complaints and response to inquiries regarding department operations. Provides ongoing education and coaching of department staff Maintains a working knowledge of all current best practices for commercial and governmental payer denials management. Disseminates current regulatory and payer trending information as formal education to appropriate staff. Evaluates team member comprehension and understanding of education. Orchestrates performance of concurrent clinical reviews for utilization review using appropriate screening criteria completes necessary review as identified and required by payers until patient discharge. Reviews must be thorough and complete on a timely basis. Communicates with team members including physicians, RN's, utilization review staff, case managers, social workers, and other applicable interdisciplinary team members regarding utilization issues. Continual tracking of in-house patient statuses and communicates with appropriate team members including you our staff and third parties regarding status issues. Orchestrate continual reviews of in-house observation patients. Create pathways for utilization review team to identify and tracks avoidable days and care optimization opportunities. Evaluate information gathered by team and identify trends and utilization management opportunities. Work with inpatient care coordination team to help identify and reinforce proper utilization management of patients. Develops and monitors concurrent review process for accuracy and quality. Ensures all days are approved appropriately before billing. Ensure compliance with federal state and 3rd party utilization management regulatory requirements. Leads and assists the utilization review staff to overturn denials concurrently. Provides oversight and assistance staff in the investigation of denials received for lack of medical necessity, continued stay, precertification through review of medical record, physician communication, and internal department communication. Provides guidance and support for the staff with writing appeals and commercial payers. Educate departments in which billing, and charge errors occur. Participates in hospital utilization review committees. Monitors and tracks the volumes of referrals sent to physician advisor services, concurrent and retrospective denials, and performance on overturn/success rates. Ensures all cases include documentation to prove necessary regulatory and/or payer specific guidelines have been followed prior to billing so that to be readily available in the event of an audit and/or denial of payment.