Title: UTILIZATION REVIEW SUPERVISOR / HC COMPLIANCE SPECIALIST I

State Role Title: Compl Offcrs, Exc Ag, Const, Hlth Safety, Transp

Hiring Range: Negotiable, commensurate with experience.

Pay Band: 4

Agency: Dept Behavioral Health/Develop

Location: Eastern State Hospital

Agency Website: https://dbhds.virginia.gov/facilities/esh/

Recruitment Type: General Public - G

Job Duties

The Utilization Review Supervisor oversees and manages the hospital’s utilization review team to optimize census management, reduce patient length of stay, maximize facility reimbursement, ensure regulatory compliance with CMS and TJC standards, and improve overall quality of care. Develops and implements departmental utilization management system plans, goals, objectives, corrective actions, policies, and procedures. Evaluates and documents performance of departmental systems frequently. Provides day-to-day supervision of staff in a constructive manner to improve performance of each individual and departmental systems. Defines, develops functional strategies, and renders decisions on policy and procedural efficacy, function, and implementation related to utilization review outcomes, census/population management, care efficiency, insurance reimbursement, and compliance with regulatory standards. Manages and monitors utilization review efforts to ensure compliance with CMS and TJC regulations, provision of care, administrative efficiency, and data management. Communicates frequently with executive and senior leadership, the Multi-Disciplinary Review Team (MDRT), healthcare providers, and treatment team members to confer on issues of policy/policy implementation, utilization review findings, justification for extended stays, required action items, and interpretation of relevant data report findings and trends.

Successful candidate must possess:
• Excellent clinical, facilitation, verbal and written communication skills. Current knowledge of medical diagnoses, treatments, and medications essential.
• Ability to collect and analyze and interpret data, comprehend, and articulate standards of care, and produce positive outcomes.
• Must be able to demonstrate critical thinking skills, professional behavior at all times as a representative of ESH and function as a positive leader of the Utilization Review (UR) team, supporting all members in the success of their positions.
• Excellent verbal and written communication skills. Familiarity with computer systems and applications. Computer literate in Microsoft suite.
• Strong organizational skills. Ability to interpret and apply departmental requirements. Ability to make sound decisions and use good judgment.
• Must be able to work under pressure and meet deadlines, while maintaining a positive attitude and providing exemplary customer service.
• Ability to work independently and to carry out assignments to completion within parameters of instructions given, prescribed routines, and standard accepted practice.
• Understanding of Medicare and Medicaid benefits.
• Ability to interpret documentation in medical records, other reports, and requirements as they relate to inpatient psychiatric hospital treatment and make recommendations for improvement.
• Must be able to perform review function as a productive member of a multidisciplinary team and facilitate positive relationships within the team as well as with clinical and administrative employees throughout the system.
• Effective written and oral communication skills are essential to this position.
• Must also be able to positively influence the work of other team members and perform other duties as assigned effectively and efficiently.
• Must be able to represent ESH in a professional and positive manner at all times.

Minimum Qualifications

• Experience with The Joint Commission (TJC), Center for Medicaid and Medicare Services (CMS) certifications and reviews is required.

• Experience with obtaining appropriate insurance authorization for patients to receive treatment at high levels of care is required.

• Experience with computer software, database development and management is required.

• Experience is supervising staff to include performance evaluations, disciplinary actions, maintaining time in automated timekeeping system and developing staff schedules.

• Experience with Power BI and utilization of the Microsoft Office Suite.

Additional Considerations

• Experience in developing and running reports and conducting statistical analysis is preferred.

• Experience with Department of Behavioral Health and Developmental Services (DBHDS) department policies and accreditation requirements is preferred.

Special Instructions

You will be provided a confirmation of receipt when your application and/or résumé is submitted successfully. Please refer to “Your Application” in your account to check the status of your application for this position.

Contact Information

Name: EASTERN STATE HOSPITAL

Phone: 757-208-7717 / REFER TO PAGEUP FOR APPLICATION STATUS

Email: EMAIL APPLICATION MATERIAL NOT ACCEPTED

In support of the Commonwealth’s commitment to inclusion, we are encouraging individuals with disabilities to apply through the Commonwealth Alternative Hiring Process. To be considered for this opportunity, applicants will need to provide their AHP Letter (formerly COD) provided by the Department for Aging & Rehabilitative Services (DARS), or the Department for the Blind & Vision Impaired (DBVI). Service-Connected Veterans are encouraged to answer Veteran status questions and submit their disability documentation, if applicable, to DARS/DBVI to get their AHP Letter. Requesting an AHP Letter can be found at AHP Letter or by calling DARS at 800-552-5019.

Note: Applicants who received a Certificate of Disability from DARS or DBVI dated between April 1, 2022- February 29, 2024, can still use that COD as applicable documentation for the Alternative Hiring Process.