Position Purpose: Under the supervision of the Utilization Managet Services Leadership, the Supervisor of Utilization Management Services RNis responsible for the management of the Utilization Management Services
The purpose of the Utilization Management Services program is to promote quality of care, cost effective patient outcomes, efficient resource utilization, while meeting the needs of the patient, family, referring physicians, agencies, and payer sources. This position has access to confidential patient and hospital information. This position makes decisions independently and/or in collaboration with others.
Incumbentprovides direct service to patients and is responsible for administrative duties and budgeting accountability.
Nature and Scope: Incumbent is responsible for:
- For planning, organizing, managing and evaluating the Utilization Management
- Monitors achievement of program objectives and implement program changes to improve outcomes.
- In collaboration with the Manager, the Supervisor prepares, administers and monitors departmental operating and capital budget and maintains budgets within allocated funds.
- Participates in the development of policies and procedures of the Department. Allocates and assigns staff for proper utilization of personnel in relation to patient, service line and organizational needs. Initiates hiring and termination decisions, and performs annual evaluations. Schedules and monitors assignments, and controls staffing levels to meet budgetary guidelines. Provides counseling and training, addresses disciplinary problems
- Promotes the role of utilization management within the Health System by effective liaison with managers, directors and physician leaders
- Participates in the planning and development of educational programs for Utilization Management staff. Coordinates and documents departmental orientation and in-service training.
- Provides expertise and direction to Utilization Management staff for solving complex clinical and financial patient situations regarding reimbursement issues, discharge planning, utilization review, continuity of care and systems management.
- Supports culture of continuous quality improvement. Works within a team environment to manage the total function of the Utilizaiton Management service. Actively participates in organizational committees.
- Participates in activities of professional associations.
- Promotes a positive, safe environment
- Keeps abreast of current professional standards in the health field and makes recommendations on changes in policy and programs.
- In collaboration with the treatment team, attending physician, and external entities, may provides direct service care to patients.
- Performs other related duties as may be requested by Administration of the Health System.
KNOWLEDGE, SKILLS AND ABILITIES:
- Thorough working knowledge of Medical Terminology.
- Demonstrated knowledge of:
- Utilization Management and Case Management principles and methodology
- Knowledge of Levels of Care (Acute care, Critical Care, Acute Rehab, LTAC, SNU, Subacute, Outpatient, Home Health, Day Tx.)
- Thorough working knowledge of:
- Government, county, private, and workers compensation funding sources.
- Eligibility criteria
- Criteria for determining level of care, and familiarity with managed care (HMO, PPO, PSO, and capitation)
- Federal and State regulatory requirements and URAC standards
- Demonstrated ability to:
- Communicate effectively with health care professionals and external case managers.
- Identify obstacles to patient progress and barriers to discharge.
- Problem solve with medical team to remove such barriers.
- Maintain professional relationships; work effectively and collaboratively with other members of the medical team.
- Actively pursue continuing education and training opportunities inUtilization Management.
- Ability to maintain knowledge regarding standards of care, case management /utilization principles and approaches, Social Services, discharge management and Spiritual Care.
- Ability to maintain confidentiality regarding the medical record.
- Understand insurance and payer requirements.
- Demonstrate the knowledge and skills necessary to provide care based on physical, motor/sensory, psychosocial, and safety appropriate to the age.
- By nature of current license for RN and department evaluation competency is demonstrated for ability to perform job duties.
This position does provide direct patient care. This position makes no adverse determinations. The 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. Minimum Qualifications: Requirements – Required and/or Preferred Education: Must have working-level knowledge of the English language, including reading, writing and speaking English. Experience: Two years experience in a care coordination/case management setting preferred. Leadership experience in a hospital environment preferred. License(s): Ability to obtain and maintain State of Nevada Registered Nurse licensure. Certification(s): National certification in Case Management (ie CCM, ACM, CPHQ) preferred. Current AHA BLS 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.