AdventHealth Corporate

All the benefits and perks you need for you and your family:

• Benefits from Day One
• Career Development
• Whole Person Wellbeing Resources
• Mental Health Resources and Support

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: Full-time

Shift: Monday-Friday

Job Location: Maitland, FL

The role you’ll contribute:

The Executive Director of Utilization Management will be responsible for developing and executing the strategic vision for AdventHealth’s World Class Revenue Cycle.  As a leader within the Revenue Cycle, the Executive Director will provide oversight for the Utilization Management functions that include, but are not limited to authorization, utilization review and denial prevention strategies for all AdventHealth excluding AMITA and Centura facilities. Knowledgeable in the areas of healthcare regulations, compliance and Revenue Cycle Management, the Executive Director works in close collaboration with Care Management, Revenue Cycle leaders, Physician Advisors and Managed Care representatives to execute denial prevention strategies, and ensure appropriate reimbursement, with a goal of optimizing patient outcomes.  This position will report directly to the System Vice President for Middle Revenue Cycle and will work collaboratively with the members of the AdventHealth Clinical, Revenue Cycle, and Care Management Teams.  Central to the Executive Director’s role is to ensure that AdventHealth medical records accurately reflects the appropriate delivery of care that facilitates optimal patient outcomes, compliance with regulatory guidelines and accurate reimbursement.

The value you’ll bring to the team:

• Oversight for AdventHealth Utilization Management teams to design, develop and implement standardized practices including workflows and Key Performance Indicators that represent best practice related to authorization procurement, patient status recommendation, medical necessity review, pre-bill denial avoidance and management strategies.
• Responsible for implementation and reinforcement of strategic World Class Revenue Cycle initiatives that are specific to the roles and responsibilities of Utilization Management for all AdventHealth facilities.  This includes providing input on configuration of IT systems that support UM workflows and outcomes reporting.
• Implement policies to decrease variability in Utilization Management practice and to establish standardized best practices processes across the organization. 
• Collaborate with Public Policy and Government Regulatory teams at AdventHealth to review, evaluate, and respond to CMS proposed rules and policies that impact reimbursement of hospital-based services.
• Collaborate with leaders from Care Management Council, Revenue Cycle, Population Health and Post-Acute, as well as other members of the AdventHealth Clinical team, to ensure workflows and processes are in alignment with identified best practice standards that promote seamless care coordination and meet regulatory requirements.
• Chair AdventHealth Utilization Management Committee that reviews existing Utilization Management, Authorization, and Denial Management strategies and develops process improvement initiatives to improve outcomes and reduce unnecessary denials.
• Responsible for managing Utilization Management Divisional Directors, Directors and Managers to evaluate operational practices, review data analysis of identified metrics; develops, implements and monitors action plans when benchmarks are not met.
• Collaborate with Division/Regional/Facility CFOs and UM leaders, with shared responsibility, to evaluate department outcomes and implement process improvement initiatives when benchmarks are not met.

The expertise and experiences you’ll need to succeed:

Minimum qualifications:

• Bachelor’s degree in Nursing, or other Allied Health related field, or equivalent combination of experience and education.
• Minimum of ten (10) years of leadership experience in Utilization Management or Acute Care Clinical Case Management with Utilization Management oversight.
• Registered Nurse, current, valid in State of Florida, or State within AdventHealth

KNOWLEDGE AND SKILLS REQUIRED:

• Expertise in evaluating and interpreting federal and state healthcare regulatory guidelines.
• Knowledge of current and future trends/practices in government and commercial payors.
• Knowledge of hospital reimbursement models and trends (ACO’s, Medicare Advantage, Value-Based Purchasing, bundled payments, etc.) and their impact to the health systems and physician providers.
• Knowledge of managed care contracting and standards, including medical necessity screening requirements, documentation and coding requirements, concurrent denials/appeals and authorization requirements.
• Knowledge of Care Management practices and processes including legal and regulatory requirements, that optimize patient outcomes in delivering the highest quality of care.
• Success as a leader with strong organizational, team development, and mentoring skills

Preferred qualifications:

• Master’s degree in nursing, business, healthcare, or related field.
• National Board Certification in Care Management (ACM or CCM)
• Certification/credentials in relevant industry trade groups representing Utilization Management, Denial Management and Revenue Cycle areas