Utilization Management ServicesPosition Purpose
The Manager of Utilization Management Services(RN) develops, oversees and directs the Utilization Management Services Departments. This position is responsible to direct improvements and innovations resulting in improved utilization of healthcare services and seamless transition of patients through the continuum of care. This position will work closely with the leadership to assist in training, defining and streamlining the patient transition through the system and on into the community post discharge. Interdepartmental and inter-facility teamwork and responsibilities will be developed to provide cost-effective, quality care to the Renown Health patient.
This position is responsible for the management, training, coordination and the effective outcome of the prior authorization, utilization management, case management, and referral activities of Health Services. This position also oversees the daily operations of the workers compensation program to include claim review, medical record review and pertaining correspondence.
Nature and ScopeThis position is responsible for the operation, i.e., direction and daily management of Utilization Management Services clinical and non clinical staff and has the authority to direct, counsel, evaluate, discipline, schedule and participate in the hiring process.
This position acts as a resource for benefit determination and provides direction for appropriate disposition of clinical services, utilizing the Director of Utilization Management Servicesfor assistance and direction with difficult or problematic cases.
This position collaborates with Claims, Provider Relations, Member Services, Finance, Pharmacy Services, Marketing, Information Resources and Quality/Disease Management.
This position requires knowledge of benefit structures for all product lines including Workers Compensation while maintaining an effective relationship with plan departments and providers to coordinate appropriate utilization of resources.
This position ensures compliance with Federal and State regulatory requirements and URAC standards.
This position does not provide patient care. The Manager makes no clinical adverse determinations.
Incumbent is responsible for assisting in the design and continuous improvement of the care management processes under the direction of Utilization Management Services Leadership. This position directs the daily operation and function of utilization review and case management, which includes:
* Oversight and development of data collection, including tracking and trending outcomes.
* Interdisciplinary collaboration with Renown Regional Medical Center and Renown South Meadows departments and management.
* Work closely with all Renown Health Entities to promote growth and quality services.
* This position is responsible for the operation, i.e., direction and daily management and has the authority to direct, counsel, evaluate, discipline, schedule and participate in the hiring process.
* This position acts as a resource for appropriate disposition of clinical services, utilizing the Director of Utilization Management Services for assistance and direction with difficult or problematic cases.
* This position collaborates with Claims, Provider Relations, Member Services, Finance, Pharmacy Services, Marketing, Information Resources and Quality/Disease Management.
KNOWLEDGE, SKILLS & ABILITIES
1.) Ability to lead strategic planning for the design, development, and implementation of Utilization Management of Case Mangement.
2.) In depth knowledge of case management practices and ability to incorporate successful current trends.
3.) Leadership skills, which model problem resolution, sound decision-making, consensus building, and effective resource utilization
4.) Ability to plan, organizes, adjusts and maintains priorities and schedules to set and meet deadlines.
5.) Ability to develop, understands, and monitors budgets.
6.) Computer familiarity and literacy. Experience in operating data base and/or spreadsheet programs.
7.) General knowledge of various health insurance models and provider contractual arrangements.
8.) Knowledge and understanding of governmental and JCAHO regulations.
9.) Strong verbal and written communication skills.
This position does not provide patient care.DisclaimerThe foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Requirements – Required and/or PreferredNameDescriptionEducation:Must have working-level knowledge of the English language, including reading, writing and speaking English. Bachelor of Science in Nursing preferred.Experience:Two years experience as a Case Manager or utilzation in home health, long-term care, acute care, rehabilitation, or utilization review required. Demonstrated experience in a managerial, supervisory or leadership role prefered. Preference will be given to candidates with case management experience in two or more service areas, and candidates with clinical experience. License(s):Ability to obtain and maintain a State of Nevada Registered Nurse license. Certification(s):National Certification preferred (i.e. Case Management (CCM), Professional Utilization Reviewer (CPUR), or Managed Care (NMCC)) preferred. Current AHA BLS/CPR certification required.Computer / Typing:Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.