Posted in General Business 6 days ago.
Location: Pittston, Pennsylvania
Utilization Manager Reviewer Supervisor, Registered Nurse (RN) - GREAT BENEFITS, FAMILY FRIENDLY HOURS!
Are you looking for a rewarding career with family-friendly hours and top-notch benefits? We're looking for qualified Utilization Manager Reviewer Supervisor like you to join Southwestern Health Resources family.
SWHR is also the parent organization of Care N' Care Insurance Co., a regional Medicare Advantage Plan serving more than 13,500 members in the region. The SWHR network includes physicians from UT Southwestern and Texas Health, and independent community primary care and specialty physicians. In partnership, our team implements physician-driven, value-based care strategies to coordinate care for more than 700,000 patients, resulting in lower costs and high-quality care. In 2020, the Centers for Medicare & Medicaid Services released the annual financial and quality results and, based on the report, SWHR is one of the nation's leading Next Generation Accountable Care Organizations, having saved nearly $120 million since joining the program in 2017.
At the heart of SWHR are people who help people. We care about those we serve and each other. To be the national leader in providing population-based healthcare, our more than 850 employees use their knowledge, data insights and clinical experience to deliver care to the right patient, at the right time and in the right setting. By connecting physicians to patients and clinical insights to better outcomes, SWHR lowers costs, optimizes value, and builds a better healthcare system for all.
• Associates Degree in Nursing Required Or,
• Bachelor's Degree in Nursing Preferred
• 2 Years Experience in managed care Required And,
• 3 Years Utilization management experience in an acute or post-acute provider, health plan or other care company experience Required And,
• 2 Years Experience in direct patient care as an RN, preferred acute care (ER, ICU, or Medical/ Surgical) Required And
• Previous experience with managed care data systems and reports Required.
• RN - Registered Nurse License upon hire required.
• Strong analytical and organizational skills. Ability to apply professional standards of practice in work environment. Knowledge of specific regulatory, managed care requirements preferred.
• Must be proficient in various word processing, spreadsheet, graphics, and database programs including Microsoft Word, Excel, Access, PowerPoint, Outlook, etc.
Position Responsibilities: The UM Supervisor will plan and direct the UM Program. This position demonstrates leadership, innovative problem solving and strategic planning to create processes and programs that translate contractual agreements into operational realities. Evidence of successful program design and implementation may be seen in improved systems performance, employee and organizational effectiveness, and customer satisfaction. In conjunction with other administrative leadership, this position is responsible for participating in the creation and promotion of new product development, implementing new operational strategies for success, and ensuring successful long-term relationships with providers. The UM Supervisor is accountable for developing a clinical infrastructure that supports all products by ensuring clinical competence and staff responsiveness while exceeding the quality expectations of all accrediting and licensing bodies. The UM Supervisor is accountable for quality management of clinical products and services.
In addition to the required qualifications, a successful Supervisor will:
• Helps recruit, train and retain competent, qualified professional staff for UM Department
• Work with physicians and their staff to design and implement processes that facilitate appropriate resource utilization without unduly interfering with quality medical practice
• As needed, provide clinical judgment by assessing if a member's reported condition meets medical necessity criteria for treatment and determine the appropriate level and intensity of care; ensure documentation is complete and accurate in accordance with (a) eligibility and benefits (b) clinical guidelines/criteria (c) legal and regulatory requirements.
• Be accountable for the overall quality of the clinical programs and processes in concert with the Medical Director and Director of Care Management.
• Be responsible for compliance with the policies and procedures, the standards of accrediting bodies and the regulations of state and local governing agencies.
• Be accountable to meet or exceed the expectations set forth in all contracts entered into by the UM Department.
• Provide a consistent, collegial professional working environment that values the diversity of individuals while supporting a team management concept.
• Comply with all compliance, regulatory and process training within the specified timeline.
• Demonstrates proficiency in the use of National review criteria and appropriate levels of care across the care continuum.
• Demonstrates a very good understanding of managed care trends, Medicare, and Medicaid regulations, reimbursement and the effect on utilization of the different methods of reimbursement.
• Fosters a spirit of teamwork in order to produce the best care possible.
• Collaborates with internal and external entities to improve accessibility standards and quality practice standards to reduce medical costs across the service delivery system. (inpatient, emergency departments, urgent care services and practitioner office settings).
• Maintains good rapport with physicians, hospital personnel, social services, agencies, etc. Acts as liaison for company with outside entities and regulatory agencies when required.
• Utilizes timely and meaningful financial and utilization reports to assist providers in efforts to alter their care delivery patterns and improve member outcomes.
• Works collaboratively with related functional departments to design a baseline quantitative analysis of Care Management Program membership. Formulates measurable program goals based on quantitative analysis.
• Assures alignment between health management programs and any related medical practice guidelines or utilization management criteria.
• Ensures that medical guidelines are current and valid and communicated to providers as appropriate.
• Ensures that Care Management Program policies and procedures meet regulatory requirements.
• Leads, coaches and develops staff while fostering innovation to improve member outcomes.
• Develops, trains and mentors staff members. 100%
Do you still have questions or concerns? Feel free to email your questions to email@example.com .