Utilization Review Manager

Employer
nThrive
Location
Naples, FL
Posted
Jul 04, 2017
Jobs Outside Higher Education
Other Jobs Outside Higher Education
Institution Type
Outside Academe


Job Description
Overview : Under the direction of the Director of Care Management, the Utilization Review Manager is responsible for assisting in carrying out the hospital's Utilization Review Plan. The Utilization Review Manager supervises and manages the UR Nurses, UR Coordinators and other staff as assigned. Ensures that concurrent reviews and retrospective reviews for hospitalized patients are performed using nationally recognized level of care guidelines such as the InterQual criteria or other evidence based criteria and pursuant to Hospital policies and procedures. The Utilization Review Manager provides leadership in Hospital programs, operations, projects, policies and procedures to ensure high quality results and financial sustainability.

Responsibilities :
  • Manages and supervises the UR Nurses, UR Coordinators and other staf as assigned with duties
  • Training staff in the use of Hospital's designated level of care criteria
  • Training and directing staff in the use of the Utilization Management Module withinCerner PowerChart
  • Evaluate staffing levels and assignments to ensure maximum efficiency and coverage for Utilization Review Services 24 hours per day, 7 days per week
  • Interviews and evaluates assigned staff performance including annual performance reviews, performance improvement plans and disciplinary steps pursuant to Hospital's Human Resource policies and procedures
  • Works with the Director of Care Management to prepare reports for the Utilization
  • Review Committee and other such committees as designated by Hospital
  • In conjunction with the Director of Care Management, develop and implement policies to reinforce high quality, efficient work flows for utilization review
  • Ensures that concurrent review and retrospective reviews for hospitalized patients are performed using nationally recognized level of care guidelines such as the InterQual criteria or other evidence based criteria and pursuant to Hospital policies and procedures
  • Ensures that InterQual level of care criteria or other criteria adopted by hospital is appropriately utilized when applied to patient stays in the hospital setting
  • Ensures reviews are entered into the Cerner UM Module in a timely fashion and within mandated timeframes and processes
  • Ensures quality of documentation of utilization review efforts and actively participates in the managing hospital utilization across the Continuum of Care to full efficiency
  • Ensures utilization review staff remain aware of the varying third-party payer requirements for hospital services and notification of such services
  • Ensures staff maintains current knowledge of the InterQual level of care criteria or other criteria adopted by Hospital
  • Tracks and monitors accuracy and timeliness of Cerner UM Module documentation by staff
  • Provides concurrent review coverage in the event of staffing shortfalls
  • Ensures appropriate communication of patient admission status to business operations staff
  • Communicates with attending physicians regarding admission status criteria and clinical signs and symptoms needed to support treatment in the hospital setting
  • Works in conjunction with Clinical Documentation Improvement department to develop and continue a positive working environment between the Utilization Review and CDI departments
  • Collaborates with the Director of Care Management and the Managers of Care
  • Coordination to ensure the effective operation of the Care Management department
  • Ensures Case Management Nurses are notified of any denials obtained during a patient's hospitalization
  • Develops and maintains relationships with third-party payers necessary to coordinate theappropriate utilization of hospital resources and meet the clinical needs of hospitalpatients
  • Maintains a positive working relationship with the Utilization Review Physician Advisor(s) and establishes guidelines for monitoring referral of cases to physician advisor(s)
  • Investigates and follows up on complaints, grievances and quality issues related to assignment of patient status and payment denials.Ensures that concurrent review and retrospective reviews for hospitalized patients are performed using nationally recognized level of care guidelines such as the InterQual criteria or other evidence based criteria and pursuant to Hospital policies and procedures
  • Ensures that InterQual level of care criteria or other criteria adopted by hospital is appropriately utilized when applied to patient stays in the hospital setting
  • Ensures reviews are entered into the Cerner UM Module in a timely fashion and within mandated timeframes and processes
  • Ensures quality of documentation of utilization review efforts and actively participates in the managing hospital utilization across the Continuum of Care to full efficiency
  • Ensures utilization review staff remain aware of the varying third-party payer requirements for hospital services and notification of such services
  • Ensures staff maintains current knowledge of the InterQual level of care criteria or other criteria adopted by Hospital
  • Tracks and monitors accuracy and timeliness of Cerner UM Module documentation by staff
  • Provides concurrent review coverage in the event of staffing shortfalls
  • Ensures appropriate communication of patient admission status to business operation staff
  • Communicates with attending physicians regarding admission status criteria and clinicalsigns and symptoms needed to support treatment in the hospital setting
  • Works in conjunction with Clinical Documentation Improvement department to developand continue a positive working environment between the Utilization Review and CDIdepartments
  • Collaborates with the Director of Care Management and the Managers of Care
  • Coordination to ensure the effective operation of the Care Management department
  • Ensures Case Management Nurses are notified of any denials obtained during a patient's hospitalization
  • Develops and maintains relationships with third-party payers necessary to coordinate the appropriate utilization of hospital resources and meet the clinical needs of hospital patients
  • Maintains a positive working relationship with the Utilization Review Physician Advisor(s) and establishes guidelines for monitoring referral of cases to physician advisor(s)
  • Investigates and follows up on complaints, grievances and quality issues related to assignment of patient status and payment denials
  • Provides leadership in Hospital programs, operations, projects, policies and procedures to ensure high quality result with duties
  • participates as an advisor to the Utilization Review Committee and attends Utilization
  • Review Committee Meetings
  • Maintains current knowledge of policies, procedures and regulatory issues related to Utilization Review and third-party reimbursement
  • Assist the Director of Care Management in preparation for audits and other regulatoryrequests
  • Actively participates in the Hospital management processes and meetings as requested by Hospital and Director of Care Management.


Qualifications :
  • Licensed as a Registered Nurse in the State of Florida
  • Bachelor's degree in Nursing (BSN) or Associate's degree in Nursing (ASN) with Bachelor's degree in a closely related field required
  • Minimum of 5 years of utilization management experience, preferably in a managed care setting and a minimum of 3 years of direct nursing experience.
  • A minimum of 3 years of supervisory or team leadership experience is also required
  • Knowledge of Medicare and Medicaid payment rules, policies and regulations
  • Strong written and verbal communication
  • Ability to effectively use MS Word, PowerPoint, Excel and Outlook required
  • Ability to evaluate medical records and other health care data
  • Ability to exercise good judgment and tact in relating to third-party payers, physicians and patients
  • Ability to establish and maintain effective and cooperative working relationships with Hospital staff and others contacted in the course of this position
  • Ability to accurately complete tasks within established times
  • Ability to effectively prioritize multiple tasks and deadlines
  • Ability to maintain confidentiality in all tasks performed
  • Excellent problem solving skills
  • Demonstrated ability to handle multiple priorities and work independently
  • Demonstrated ability to effectively present information and respond to questions from small groups or on a one-on-one basis
  • Demonstrated ability to deal with problems involving several concrete variables in standardized situations
  • Strong presentation skills


Preferred Skills :
  • Certification in clinical case management of utilization review strongly desired


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Company Description
nThrive is the leader in providing end-to-end revenue cycle services, technology and education solutions. Previously known as MedAssets, Precyse and Equation, each formerly a leader in its own right, we've combined our talents and capabilities into a single enterprise. At nThrive, we are people who are passionate about empowering health care for every one in every community. We work together to transform financial and operational performance, enabling health care organizations to thrive.

Equal Opportunity Employer EOE M/F/D/V


Naples, FL

fc6ed81d9

Mon, 3 Jul 2017 14:10:39 PDT

PI98512601