RELOCATION ASSISTANCE AVAILABLE!!

Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Coordination of Care

Job Family

Management

Work Shift

Days (United States of America)

Summary

Participates in and oversees the operational and personnel activities as it relates to Utilization Management needs and requirements. Responsible for the coordination and management of denials and subsequent outgoing appeals between payers and Cape Fear Valley Health System. Supports a collaborative coordinated process among departments within the community, health system, physician, and support staff to promote effective management and cost containment of patient care across the healthcare continuum. Fosters teamwork and integration of services for the staff in Coordination of Care and the customers served. Adheres to patient experience initiatives and champions customer service excellence.

Major Job Functions

The following is a summary of the major essential functions of this job.  The incumbent may perform other duties, both major and minor, that are not mentioned below.  In addition, specific functions may change from time to time:

• Leads, coordinates and oversees the workload of the Utilization Management RNs
• Reviews and recommends policies and procedures in relation to Utilization Management
• Maintains updated knowledge of Medicare and Medicaid regulation changes and provides communication and facilitates new process changes as necessary to maintain compliance as it relates to Utilization Management activities
• Audits staff’s Admission and Concurrent Reviews for accurate application of criteria
• Provide education to staff as a result of comprehensive analysis of data gathered and trends identified
• Responds proactively to demand letters received from all payers, ensuring that contacted timeframes for appeals are met
• Serves as Medical Necessity Reviewer in conjunction with Physician Advisor for Recovery Audit Contractor Team
• Educates on and facilitates compliance with Joint Commission requirements, audits, compliance, and record maintenance
• Identifies and develops department and individual performance audit tools to measure compliance and quality
• Identifies opportunities and solution sets and strategies to improve utilization management departmental processes to meet the evolving needs of specific patient populations, hospital, and community
• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training: 

• Associate’s degree in Nursing required
• Bachelor's degree in Nursing preferred
• Current Registered Nurse licensure in North Carolina or Compact state licensure required

Work Experience: 

• 3 years’ experience in Utilization Management required
• 1 year of Case Management experience preferred
• 1 year prior experience with data and statistical analysis preferred
• 3 years in managed care claims/reimbursement or other healthcare field preferred
• Must have management experience in Utilization Review, experience with insurance claims.
• Must have an understanding of working with a revenue cycle.
• Must understand Epic and Epic reporting.
• Must be able to build reports to manage staff and improve upon an already standing UM committee.
• This position requires working every 4th or 5th weekend.

Knowledge, Skills, and Abilities Required: 

• Proficiency in reading, writing, and speaking the English language
• Knowledge of professional nursing principles, clinical processes, and clinical interventions
• Working knowledge of Medicare guidelines, as they appear in Federal Register, pertinent to inpatient hospital and ambulatory services
• Ability to perform medical record reviews interpreting, abstracting, aggregating, analyzing, and reporting complex clinical data obtained from medical records
• Knowledge of clinical practice guidelines and the appropriateness of clinical interventions
• Knowledge and ability to implement a quality improvement process
• Strong analytic, data management and research skills
• Excellent interpersonal communication and negotiation skills
• Ability to communicate effectively and work with people of all social, economic, and cultural background
• Self-motivated, proven written, telephonic, and electronic communication skills
• Assertive and persuasive interactions with customers, peers, management, and core staff served
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components
• Understanding of criteria and measurement outcomes
• Knowledge of third-party payor requirements including managed care, reimbursement, and utilization management
• Proficiency with various computer programs, to include Microsoft Office, EPIC, InterQual, MCG, Teams, Webex
• Working knowledge of Coordination of Care, Medical Management, Utilization Review, Performance Improvement, Criteria-Based Management
• Ability to demonstrate leadership, respect, and team building
• Flexible, open-minded, and adaptable to change

Physical Requirements: 

• Some light carrying and lifting may be required
• Occasional walking may be required to access all areas of the Medical Center
• Ability to effectively communicate orally with patients, family members, personnel, and physicians
• Near visual acuity to proofread hand or typewritten materials
• Manual ability to use telephones and computer keyboard
• Position involves sitting for extended periods of time performing data entry into a computer

#CFVH-2026

Required Licenses and Certifications

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity