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

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.

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.