Overview

Salary: $90,000.00 – $105,000.00

Client is seeking a Manager, Utilization Management to join their team.

Licensed Registered Nurse

Skilled & knowledgeable in utilization management, Medicare& insurance regulations.  Must possess strong leadership skills.  Knowledge of managing to productivity metrics.  Ability to collaborate as well as educate members of the organization on utilization management.

Leads utilization management practice, for a designated group of hospitals, in collaborating with all members of the health care team, patient and family (or significant others) to coordinate timely and efficient delivery of required services to result in:

  • Positive patient health care outcomes
  • Appropriate reimbursement
  • Improved efficiency
  • Improved inpatient throughput
  • Increased patient/health care team satisfaction

Establish an environment to support excellence:

  • With peer managers, sets policies to support documentation of reviews, application of appropriate criteria and/or guidelines and documentation of review outcomes in collaboration with peer managers.
  • Monitor productivity and quality of staff work product and outcomes, ensure accountability.
  • Serve as a resource in complex decision making, identification and reporting of trends, and problem solving.

Manage to metrics:

  • Ensure accurate and timely review to meet compliance and/or payer specific requirements.
  • Perform analysis of daily, weekly monthly, quarterly reports to adjust staffing and processes for optimal outcomes.
  • Establish and meet goals for productivity through implementation and maintenance of appropriate division and ED coverage based on facility metrics.
  • Inform leadership via consistent standard reporting.

Collaboration:

  • Work with physicians to support staff, review processes.
  • Partner with CM Documentation Integrity Advisor to support ongoing training and monitoring to drive consistent high performance.
  • Denials management team, in support of denial avoidance.
  • Work with managed care contracting with regard to payer process changes and trends.

*This role may encounter Protected Health Information (PHI) as part of regular responsibilities.  Employees must abide by all requirements to safely and securely maintain PHI for our patients.  Annual training, the Code of Conduct and  policies and procedures are in place to address appropriate use of PHI in the workplace.

Position Requirements:

  • Minimum 5 years clinical nursing experience
  • Minimum 3 years of utilization review or case management experience
  • Must have comprehensive knowledge of the care continuum, alternate environments of care
  • Experience in a management or supervisory position
  • Excellent oral, written and interpersonal communication skills
  • Ability to lead interdisciplinary teams to achieve desired outcomes
  • Project Management skills
  • Patient care process and clinical analysis skills
  • Experience in developing and managing operation and capital budgets
  • Demonstrated ability to use PC’s, Microsoft Office suite, and general office equipment
  • Excellent problem solving skills

Education Requirements:

  • Graduate of an accredited nursing program
  • Bachelor’s degree

License Requirements:

  • Current RN licensure in the State of Ohio

Preferred Qualifications:

  • CCM certification
  • Master’s degree

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