Utilization Review and Clinical Documentation Improvement Manager

Job Description

Networks Connect is conducting a search for a Utilization Review and Clinical Documentation Improvement Manager to work in office in Washington DC. We are seeking an experienced and dynamic Utilization Review (UR) and Clinical Documentation Improvement (CDI) Manager to oversee the operations of both the Utilization Review and Clinical Documentation Improvement departments. The ideal candidate will supervise and manage staff, ensure compliance with regulatory standards, and lead hospital-wide initiatives aimed at improving clinical care, documentation practices, and resource utilization. This role involves close collaboration with interdisciplinary teams, including physicians, nurses, and case managers, to improve clinical documentation, optimize patient care, and streamline healthcare operations.

Key Responsibilities:

• Supervise Utilization Review & CDI Teams: Manage daily operations of the Utilization Review (UR) and Clinical Documentation Improvement (CDI) departments, ensuring team performance meets organizational and departmental standards.
• Provide Education: Lead educational initiatives on clinical care, levels of care, and financial issues related to healthcare delivery. Facilitate training for staff and hospital teams on clinical documentation guidelines and case management best practices.
• Analyze & Report Data: Collect, analyze, and report on case management activities, payer interactions, resource utilization, and clinical denials.
• Lead Process Improvement: Participate in planning, developing, and implementing clinical documentation management programs to improve documentation accuracy and financial outcomes.
• Monitor Performance & Outcomes: Track and evaluate data to measure the effectiveness of process improvements, ensuring alignment with departmental goals and organizational objectives.
• Collaborate Across Teams: Work closely with coding leadership, clinical teams, and payors to ensure accurate documentation and resolve issues related to clinical denials and authorization processes.

Qualifications:

• Education: Master’s Degree in Healthcare Administration or related field (Required)
• Experience: 7+ years of healthcare experience, including 3 years in a supervisory role (Required)
• Technical Skills: Proficient in Microsoft Office Suite (Word, Excel, PowerPoint, Access) and Windows environments.
• Certification Requirements:
  • Registered Nurse (RN) license in the District of Columbia (Required)
  • Basic Life Support (BLS) certification (Required)
  • CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner) preferred
  • Case Management Certification (CCM or ACM) preferred

Required Knowledge & Skills:

• In-depth knowledge of clinical documentation improvement, medical management criteria, and tools like Interqual and Milliman.
• Strong oral and written communication skills with the ability to present data clearly.
• Expertise in patient care guidelines, documentation standards, and the impact of healthcare regulations (e.g., JC, CMS).
• Proficiency in data analysis and the ability to interpret trends using tools like Microsoft Access and Excel.
• Service Excellence mindset with the ability to educate and mentor staff.

Functional Accountabilities:

• Operations Management – General: Oversee daily team operations, manage staffing, and optimize team productivity. Participate in budget development and track departmental spending.
• Clinical Resource Management (CRM) & Utilization Review (UR): Serve as a subject matter expert on Interqual and MCG guidelines, mentor staff, and work with Managed Care to improve authorization processes.
• Clinical Documentation Improvement (CDI): Monitor trends in clinical documentation, collaborate with coding leadership, and develop educational strategies for physicians and providers.
• Performance Improvement: Ensure compliance with regulatory standards, track operational and financial data, and implement strategies to reduce clinical denials and improve reimbursement.

Organizational Accountabilities:

• Demonstrate a commitment to teamwork, communication, performance improvement, and cost management.
• Ensure a focus on patient safety and continuous improvement in healthcare delivery.

Earnings

$100,00-$160,000 salary

Category

Revenue Cycle