RN System Director Utilization Management

About Tufts Medicine:

Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. The health system is the principal teaching affiliate for Tufts University School of Medicine. The strong relationship between Tufts Medicine and Tufts University School of Medicine is evident in our governance, academic and research structure. Tufts Medicine is comprised of the following clinical entities:

·       Tufts Medicine Professional Group (TMPG)

·       Tufts Medicine Integrated Network (TMIN)

·       Tufts Medical Center

·       Lowell General Hospital

·       MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford

·       Tufts Care at Home

Job Overview

The position coordinates the design, development, implementation, and monitoring of the organization’s utilization review functions. The position establishes the department’s strategy and vision and oversees daily UM operations.  The position functions as the internal resource on issues related to the utilization of resources, coordination of care across the continuum and utilization review and management. The position develops and leads the Utilization Management operations, strategy and implementation of the Utilization Management model and tactics. The position is responsible for assuring success in financial management, human resources management, leadership, quality and operational management objectives. The position consistently demonstrates the core values of Tufts Medicine and serves as a role model for other employees.

Job Description

Minimum Qualifications:

1. Bachelor of Science in Nursing (BSN).

2. RN Licensure.

3. Current certification in case/utilization management (ACM, CCM, CMAC)

4. Seven (7) years of UM/Case Management experience in an acute-care hospital or multi-hospital system, including two (2) years of supervisory experience.

Preferred Qualifications:

1. Master’s in Nursing

2. Fluent in CMS Two-Midnight, Inpatient-Only, Condition Codes 44 & W2, MOON/IMM, and payer-specific admission guidelines

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list.  Other duties and responsibilities may be assigned.

1. Serves as the UM first point of contact for Tufts Medicine.

2. Responsible for addressing complex issues, processes and root causes such as those stemming from an inability to achieve agreed upon metrics and targets.

3. Leads the development of policies to decrease variation in practices for Utilization Management.

4. Coordinates the setting of Utilization Management metrics and tracking across the markets.

5. Collaborates and meets regularly with Utilization Management, as well as corporate and revenue cycle leaders, to review metrics and discuss any operational issues. Coordinates Utilization Management meetings and deliverables.

6. Acts as Co-chair System UM Committee Meetings.

7. Responsible for resolving issues associated with performance in accordance with the process standards outlined.

8. Acts as the first point of contact for addressing any human resource related issues.

9. Responsible for facilitating and assigning representative(s) to participate in any UM initiative(s) at the corporate or local level as mutually agreed upon and approved by leadership.

10. Ensures adequate staff with the appropriate expertise to deliver timely information and to respond to facility, patient care team and payor inquiries regarding authorization number and authorized days, admission status and review, and concurrent reviews.

11. Responsible for daily operations, such as setting leadership behavior and human resources. Ensures ongoing collaboration with the Physician Advisor(s) and meet regularly with revenue cycle and finance leadership, attend various system-based revenue cycle, finance and operational meetings, as requested, and collaborate with site Case Management leadership.

12. Available to intervene in cases which fail to meet screening for admission or continued stay due to medically neuticessary care and/or if there is disagreement between UM RN and attending Physician in determining appropriate patient status.

13. Maintains ongoing collaborations and discussions with Clinical Documentation Integrity (CDI) and Coding leadership to review data and identify areas for clinical documentation improvement.

14. In the absence of a Physician Advisor, the hospital Chief Medical Officer (CMO) will be consulted.

Physical Requirements:

1. Normal office settings

Skills & Abilities:

1. Knowledge of InterQual® and MCG® medical-necessity criteria

2. Experience with Lean/Six Sigma or similar methodology to redesign and improve workflows

3. Proven ability to run multi-disciplinary projects

4. Confident presenter to executives, physician committees, and payer medical directors

5. Skilled at writing clear policies, job aids, and appeal letters

6. Ability to manage conflict between clinical teams and finance/rev cycle priorities

Job Profile Summary

​This role focuses on activities related to revenue cycle operations such as billing, collections, and payment processing.  In addition, this role focuses on performing the following Patient Access duties: Performs the administrative and financial-clearance duties necessary to facilitate the procurement of clinical services by patients. Collects patient's necessary demographic and financial information from physician offices, acute-care entities, or the patients themselves, schedules services for patients, and handles referrals from primary care doctors to ensure patients are scheduled for recommended appointments/procedures, etc.    A management role that supervises employees focusing on tactical, operational activities within a specified area, with the majority of time spent overseeing area of responsibility, planning, prioritizing and/or directing the responsibilities of employees. Goal achievement is typically accomplished through performance of direct and/or indirect reports.  A role that directs a department or small unit that includes multiple teams led by managers and/or team Leaders.  Responsibilities typically include: ownership of short to mid-term (1-3 years) execution of functional strategy and the operational direction of the Department, problems faced are often complex and require extensive investigation and analysis, and requires ability to influence others to accept practices and approaches, and ability to communicate and influence executive leadership.

At Tufts Medicine, we want every individual to feel valued for the skills and experience they bring. Our compensation philosophy is designed to offer fair, competitive pay that attracts, retains, and motivates highly talented individuals, while rewarding the important work you do every day.

The base pay ranges reflect the minimum qualifications for the role. Individual offers are determined using a comprehensive approach that considers relevant experience, certifications, education, skills, and internal equity to ensure compensation is fair, consistent, and aligned with our business goals.

Beyond base pay, Tufts Medicine provides a comprehensive Total Rewards package that supports your health, financial security, and career growth—one of the many ways we invest in you so you can thrive both at work and outside of it.

Pay Range: