Job DescriptionOversee the management of patient care utilization, ensuring appropriate healthcare services are provided while optimizing resource use. This individual will be responsible for leading a team of nurses who review medical necessity, appropriateness and efficiency of healthcare services. Ensure compliance with regulatory requirements and maintain high standards of care.
Responsibilities- Supervise and lead the UM nursing team and Pre-Certification Specialists, ensuring the review of patient cases for appropriate medical necessity and care protocols
- Develop, implement and maintain UM policies and procedures in accordance with healthcare regulation and organizational standards
- Conduct regular training and provide ongoing support for UR team to improve knowledge and performance
- Collaborate with physicians, other healthcare providers and insurance companies to review and improve treatment plans. Ensure all services are medically necessary and cost effective
- Evaluate and analyze healthcare utilization trends, identify opportunities for improvement and solutions to improve outcome
- Monitor and ensure compliance with regulatory requirements including Medicare, Medicaid and other payer policies
- Prepare and present reports on utilization metrics, case reviews and outcomes to administration leadership groups
- Resolve complex case issues and provide guidance on challenging utilization decisions
- Ensure accurate documentation of all UM reviews, ensuring compliance with internal and external audit
- Foster effective communication between departments, stakeholders and healthcare professionals
QualificationsEducation RequirementsRequired: Bachelor Degree
- Bachelor of Science in Nursing, with an active unrestricted license
Preferred: Master's Degree
- Nursing or other clinical discipline, Health Administration, Finance, Business Administration, or a related field
License or Certification RequirementsRequired: License
- Nursing degree (RN, BS, BSN, or advanced degree) and unrestricted active nursing license
Experience RequirementsRequired: 5 years
- Nursing experience with at least 2 years in Utilization Management or case management role
Preferred: 2 years
- Leadership or management experience in nursing or related field
Core CompetenciesKnowledge:
- In depth knowledge of healthcare utilization management processes, medical terminology and clinical guidelines
- Familiarity with payer requirements and regulation including Medicare, Medicaid and private insurers
- Working knowledge of applications that are used to enhance utilization management based on evidenced based approach and guidelines
- Strong knowledge of Microsoft Office applications
Skills:
- Analytical Skills: The ability to analyze large data sets, determine trends, synthesize results, and deliver prioritized details through effective reporting
- Communication Skills: Strong communication and interpersonal skills for effective collaboration and education
- Problem-Solving Skills: The capacity to understand issues, derive many potential solutions, troubleshoot discrepancies, and understand systematic approaches to problem resolution
Abilities:
- Attention to Detail: Precision is essential when reporting critical analysis to inform decision-making and operational change
- Time Management: Managing multiple tasks and deadlines while prioritizing work is essential in a fast-paced healthcare environment
- Technology Proficiency: Beyond EHR systems, familiarity with various billing software and technology tools
Work Environment: This position may involve working in a variety of clinical and administrative settings, requiring adaptability and a proactive approach to problem-solving.
Physical Demands: Frequent reaching, sitting, walking, and standing may be required. No special coordination beyond that used for normal mobility and handling of everyday objects and materials is needed to perform the job.
