JOB SUMMARY:The Manager for (CMC) Correctional Managed Care (UR) Utilization Review has responsibility for daily department operations. This includes the management of the Utilization Review Case Managers in the support of the optimal functionality of the department to provide exceptional customer service and patient support.
ESSENTIAL JOB FUNCTIONS:- Supervises the operational management of the (UR) Utilization Review program to ensure high-quality, cost-effective service/ outcomes, and a safe and efficient work environment.
- Monitors the work performance of the URCM staff and provides guidance and intervention as needed to assist staff in achieving both department and staff-specific goals.
- Prepares the department work schedule and time keeping, ensuring adequate staff coverage and completion of work.
- Provides back-up support for telephone UR to ensure adequate staff coverage.
- Provides leadership to the department and promotes teamwork.
- Assist in the implementation of UR policies and procedures.
- Assist with the identification of department SOPs, Flow diagrams, and job aids needed.
- Responsible for the orientation of new personnel and integration into the department as fully trained (URCM) Utilization Review Case
- Acts as an expert resource for clinical resources to include Optum (InterQual), Urgent Referral guidelines, and others as defined by CMC.
- Able to review quality of care issues that may arise during department duties and identify areas of potential medical liability.
- Contributes to the overall success of UTMB Correctional Managed Care.
- Adheres to internal controls as established by the department.
- Adheres to internal controls and reporting structure established for department.
- Performs other related duties as required.
KNOWLEDGE/SKILLS/ABILITIES:- Assumes responsibilities for remaining current on job-related knowledge, skills, and in-service/ certification requirements as deemed appropriate for the position.
- Assumes responsibilities for remaining current on job-related knowledge, skills, and in-service/ certification requirements as deemed appropriate for the position.
- Must take the initiative and be willing and able to learn multiple aspects of the job.
- Demonstrates collaboration, professionalism, and ability to work with all health care providers and staff.
- Amenable to perform a variety of marginal, clerical duties not listed but to be determined as needed.
- Demonstrates support of the department as both an active participant and a leader.
- Demonstrates capacity to manage "crisis situations" professionally and effectively.
- Demonstrates skill in prioritization of work.
- Demonstrate excellence in communication of clinical issues to non-nursing utilization review staff
- Active participation in performance improvement and acting as a leader in achieving department goals.
SUPERVISION:Received: Director, CMC Utilization Review
Given: Utilization Review Case Manager, CMC
DECISION-MAKING RESPONSIBILITY:- Budgetary decisions
- Personnel
- Data analysis and planning
- Management of emergency situations
- Quality Improvement
EQUIPMENT:Standard office equipment
WORK ENVIRONMENT:Standard office environment. May be required to work within the confines of a prison, jail, or juvenile detention center.
Security clearance is required; pre-employment drug testing is also required.
REQUIRED EDUCATION/EXPERIENCE:- Graduate from an accredited school of professional nursing and currently Texas nursing licensure as a professional registered nurse.
- Minimum of five years full-time wage-earning experience as a professional nurse in a health care setting with at least two years in utilization review and /or case management experience.
- Two years of supervisory and/or management experience.
PREFERRED EDUCATION/EXPERIENCE:- Master's Degree
- At least three years of adult care nursing experience
LICENSES, REGISTRATIONS, OR CERTIFICATIONSActive and valid nursing license in Texas
Salary is commensurate with years of relevant work experience.
