Description Position Purpose: Perform duties to conduct and manage the day to day operations of the utilization management function. Communicate with staff to facilitate daily department functions.
Review analyses of activities, costs, operations and forecast data to determine progress toward stated goals and objectives.
Promote compliance with federal and state regulations and contractual agreements.
Develop, implement and maintain compliance, policies and procedures regarding medical utilization management functions.
Develop, implement, and maintain utilization management programs to facilitate the use of appropriate medical resources and decrease the business unit's financial exposure.
Compile and review multiple reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management.
Facilitate on-going communication between utilization management staff and contracted providers.
Develop staff skills and competencies through training and experience. Available to non-clinical staff as a resource for clinical questions.
Qualifications Education/Experience: Bachelor’s degree in related field or equivalent experience. Bachelor’s degree in nursing preferred. 3+ years utilization management and recent nursing experience in an acute care setting particularly in medical/surgical, pediatrics, or obstetrics and management experience. Thorough knowledge of utilization management and clinical nursing. Familiarity with Medicare and Medicaid managed care practices and policies, CHIP and SCHIP. Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.
License/Certification: RN license. Case Management Certification preferred.