General Summary

• Assume 24-hour accountability for managing the functions of Utilization
• Management. With the Manager of Case Management and the Manager of Social Work, serves as the central resource to the Director of Care Management to develop strategies which are efficient, effective, timely, patient-centered, and support appropriate financial reimbursement.
• To meet accountabilities of the Care Management Dashboard collaborates with all disciplines, departments, payers, system partners, vendors, and community agencies to optimize clinical outcomes within best practice, ethical, legal, and regulatory parameters.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by staff assigned to this classification. They are not to be construed as an exhaustive list of all duties.

• Direct oversight of the Utilization Management Lead (s) and frontline Utilization Review staff.
• Completes annual and interim performance reviews for all staff and contributes to performance reviews of other professionals and support staff as requested. Develops a growth plan for each employee.
• Manages hiring and performance management of staff.
• Keeps key statistics and participates in the maintenance of the Care Management Dashboard, using data to better understand strengths and weaknesses of the hospital and department, and to determine needs, decisions, and strategies.
• Manages, and constantly evaluates staffing levels, assignments, skills, learning needs, and deployment of staff.
• Manages structure and process to facilitate participation by physicians, rehabilitation, pastoral care, care coordinators, and other health professionals in multidisciplinary care planning, care delivery, and discharge planning.
• Participates and fosters performance improvement within the department and organizationally.
• Oversees operational budget
• Partners with physicians and the Physician Advisor (s) for effective relationships with physicians, services, specialties, etc.
• Establishes collaborative relationships with owner of hospital contracts and reimbursement.
• Participate in payer, Revenue Management Cycle and interdepartmental meetings to promote knowledge, troubleshoot, and resolve issues related to utilization management.
• 1Serves as educational and communications resource to Administration, Department Leadership, physicians and other necessary groups regarding the utilization review/management activity process.
• Maintains a leadership role in the Utilization Committee and Plan as it relates to the conditions of participation.

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Education and Experience

• Bachelor's Degree in nursing or other related health care field required; A Bachelor's Degree with 5 years of Healthcare experience will be considered in lieu of a Healthcare Degree; Master's Degree preferred or an equivalent combination of education and experience in business, nursing or a related allied health field.
• Previous experience in progressive leadership or successful project implementation.

Knowledge, Skills and Abilities

• Knowledge of healthcare law and regulations related to acute care and the immediate post-acute continuum.
• Proficient in evidenced based medical necessity criteria for surveillance.
• Highly effective verbal and written skills are required.
• Excellent analytical and team building skills, as well as the ability to prioritize and work independently are required.
• Must possess the ability to work collaboratively with other disciplines.
• Ability to work with Hospital/Care Coordination related software programs required.
• Ability to demonstrate knowledge and skills necessary to provide care appropriate to the patient population(s) served. Ability to demonstrate knowledge of the principles of growth and development over the life span and ability to assess data reflective of the patient's requirements relative to his or her population-specific and age specific needs.

Patient Safety

Ensures patient safety in the performance of job functions and through participation in hospital, department or unit patient safety initiatives.

• Takes action to correct observed risks to patient safety.
• Reports adverse events and near misses to appropriate management authority.
• Identifies possible risks in processes, procedures, devices and communicates the same to those in charge.

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