Manager - Utilization Review

Description

The Utilization Management Review Manager provides a key role in facilitating long-term success of the UM program by providing day-to-day intense oversight of Utilization Management at the facility level. The Utilization Management Review Manager supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. The Utilization Management Review Manager will work in collaboration with the clinical documentation improvement and utilization management team of clinicians, coding professionals, physicians, physician's assistants' and certified registered nurse practitioners to ensure accurate and timely clinical documentation in the medical record that supports the admission status and coding process in attaining sound clinical entries in the medical record. Specific management of care collaboration includes observation utilization and denial management. The Utilization Management Review Manager is responsible for increasing program awareness (Utilization process and program benefits) to the entire hospital staff. The Utilization Management Review Manager must fully understand data collection and analysis for hospital use of professional services. The Utilization Management Review Manager will support ongoing communication and education on documentation opportunities, utilization review, coding and reimbursement issues, as well as performance improvement methodologies to physicians and entire hospital staff. The Utilization Management Review Manager will function as the UM Committee co-chair and participate in CDMP® Task Force (CDMP® team) meetings.

Responsibilities

Accountability for Utilization Management Program Success.

Responsible for maintaining effective and efficient processes for determining the appropriate admission status.

Collaborate with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status.

Develops a collaborative clinical documentation improvement and utilization management teams.

Functions as the UM committee co-chair member.

Provides utilization review and CDI team, physicians, administration and UM committee ongoing feedback.

Creates and disseminates reports from electronic tools and formulates action plans based on results.

Assist with preparation of discussion and appeal letters for Medicare/Medicaid medical necessity denials.

Develops strategies that address program initiatives and prevent denials.

Facilitate the annual update of InterQual (or other screening tool) software (collaborating with Information Systems staff), create training tools, and provide training to RN CMs.

Manages multiple priorities effectively.

Is responsible for department’s operational excellence; ensures department delivers quality services in accordance with applicable policies, procedures, and professional standards.

Is responsible for the fiscal management of department; assures proper utilization of organization’s financial resources.

Manage team members which include orientation, development and evaluation of personnel, and monitoring the provision of delivering quality services. Participates in the recruiting, interviewing and selecting of team members following policies, guidelines and applicable laws. Evaluates their performance relative to job goals and requirements. Provides coaching to staff, recommends in-service education programs, and ensures adherence to internal policies and standards.

Effectively communicates departmental, organization, and industry information to staff.

Maintains current knowledge/certification. Pursues professional growth and development.

Qualifications

Minimum Education

Associates Degree Nursing Required

Bachelor's Degree Nursing Preferred

Minimum Work Experience

5 years clinical and/or coding adult acute care experience in Med Surg, Critical Care, Emergency Room or PACU. Required

1-3 years case management and/or utilization review experience. Required

2 years management or supervisory, leadership experience. Required

Licenses and Certifications

Registered Nurse Licensed State of Florida or eligible compact license Upon Hire Required

Required Skills, Knowledge and Abilities

Organizational, analytical, writing and interpersonal skills.

Excellent knowledge of Word/Excel/Power Point.

Knowledge of Medicare Part A and Part B.

Knowledge of ICD-10, DRG and other hospital reimbursement methodology Knowledge of regulatory environment.

Understand and support Utilization Review strategies.

General understanding of hospital-based quality initiatives (preferred).

Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments (training provided.)

Knowledge in areas of: Medicare and Medicaid UM regulations, McKesson InterQual, Medicare Inpatient Only List, RAC, QIO, MAC, and Denial Management