Director, Clinical Revenue Cycle

Summary

Provides operational oversight and strategic planning and execution for all areas of the Clinical Revenue Cycle. The Director of Clinical Revenue Cycle is responsible for planning, organizing, coordinating, managing, implementing, evaluating, and developing all areas of the Clinical Revenue Cycle, including but not limited to, Utilization Review, Clinical Appeals, CDM Management, and Revenue Integrity.

This position serves a critical role in acting as a liaison between clinical and non-clinical departments, ensuring positive financial outcomes that match the delivery of care received by patients. Must guide and direct the utilization team to provide optimal financial outcomes for the facility.

This position develops and integrates strategies to ensure financial management, leadership, quality and operational management objectives. The Director functions as the internal resource on issues related to appropriate utilization of resources, coordination of care across the continuum and utilization review and management.

Essential Duties and Responsibilities

These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned.

• Supervise the performance of Utilization Review, Revenue Integrity, and CDM team members

• Evaluate staff performance and productivity to ensure optimal use of resources

• Direct the overall activities of the Utilization Review team and implement efficiency measures

• Develop and achieve departmental goals and objectives to ensure organization metric goals are achieved

• Perform random audits to ensure appropriateness and timeliness of Utilization Review activities

• Monitor documentation in the software platforms for appropriate use

• Work closely with peers and leadership team to ensure the timely resolution of issues

• Maintain data and metrics to submit to the Revenue Cycle Committee

• Report and develop timely reports to submit to the Utilization Management Committee as directed

• Review Utilization Review plans annually, revising as necessary, and submit for approval by the Utilization Committee and Medical Executive Committee

• Assist with development and maintenance of department budget and ensure that the department operates within the allocated funds

• Manages all appeals related to denials for all payers

• Implement strategies to reduce denials while optimizing revenue

• Ensure all hospitalized patients have the correct admission status so that an appropriate claim can be submitted to the payer

• Oversee and coordinate the Utilization Review program's development to include the hospital resources as necessary to support its success

• Facilitate and foster staff and physician participation in the development and/or process revenue cycle operations

• Engage in improvement activities and events that maximize financial support for the hospital

• Communicate Utilization Review results through appropriate committees

• Develop and implement a continuous process improvement plan

Supervisory Responsibilities

Reports to: Sr Director, Revenue Cycle

Supervises: Utilization Review RN, Revenue Integrity, CDM Management

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience

Minimum Required Education:
Bachelor’s degree in healthcare administration, nursing, health informatics, business, or a related field. Five years of management experience will be considered in lieu of degree.

Preferred Education:
Master’s degree

Experience:
Three (3) years of experience in direct patient care RN experience in an acute care environment. Five (5) years of experience in Utilization Review or Case Management department performing utilization review activities, with at least two (2) years of utilization review for an acute care environment.

• Certified Professional Coder (CPC) preferred

• Certified Case Manager (CCM) or Accredited Case Manager (ACM) within 2 years of eligibility

• Experience with Epic EMR is required

Certificates, Licenses, Registrations

If the degree is in Nursing, an active RN license is required