This position has responsibility for the day to day operations and decisions of the assigned clinical services related to utilization management of referrals for ambulatory services. The supervisor will be responsible for primary oversight of utilization review nurses and support staff. This position will support the UM Manager and Director in achieving Medical Management initiatives for cost saving, implementing growth and development plans, while supporting the strategic goals of the foundation.
Essential Functions and Responsibilities of the Job
Ability to collaboratively communicate and assess the deployment of all assigned tasks and responsibilities to UM team.
Demonstrates consistent performance, monitor staff for implementation of Utilization Management regulation, guidelines and standards to meet NCQA/CMS and health plan compliance.
Consistently demonstrates ability to practice and model a positive communication style that fosters open and honest feedback and contributes to a team centric environment that produces top quality results.
Sets and models high performance standards characterized by integrity ensures effective and productive work ethics promoted on the Utilization team.
Be present and available to team members for problem solving and stepping into open positions to maintain productivity to meet regulatory compliance.
Follow company policies, procedures and directives
Assist with reviews, hiring, coaching and payroll of all UM staff members.
Prioritize and multitask
Essential Job Outcomes
Manages day to day oversight of activities associated with utilization management nurses for the management of referrals, regulatory compliance, critical analysis of criteria and clinical history to make referral determinations for approvals and or denials.
Independently analyzes and assigns coverage by allocating resources and directing the day to day activities to departmental advantage.
Develop and implement quality and productivity standards then establish the expectations with the staff in the performance of their jobs.
Develop and maintain templates, forms, reports, and other job aides that will assist the staff in meeting the needs of the department, patients and providers of the organization as it relates to utilization management.
Ensure referrals are reviewed and completed in Epic system in timely fashion.
Interface with other departments to assist with problem solving of referral and patient issues.
Identify, develop and conduct training for staff and/or coordinate with trainer for new hires or when additional training is needed.
Participate in quality improvement activities such as health plan audits.
Mentor new staff members.
Assist with reviewing, revising, and developing policies and procedures for the department as needed.
Monitor time and attendance of assigned staff.
Provide support to Clinical Manager and Director.
Participate in other duties as assigned.
Ability to problem solve to logical conclusion and demonstrates initiative and responsibility
Experience
Must be licensed as a Registered Nurse or have a college degree as an LVN.
Minimum of years' experience in utilization management and Managed Care.
Minimum 2 years leadership experience in managing teams or processes.
Excellent communication skills, including written and verbal
Knowledge of regulatory requirements, Health plan contracts, delegation requirements, Medicare, Managed Care, utilization management.
Working knowledge of evidence based guidelines/criteria (i.e.: MCG, InterQual, Hayes); Health plan medical policy and understanding of clinical division of financial responsibilities.
Working knowledge of Microsoft applications - Word, Excel
Ability to perform independent problem solving and process management.
Flexibility in work schedule
Education
Bachelor's Degree in nursing, Registered Nurse licensed preferred or Licensed Vocational Nurse with 3 plus years of industry experience .
