The Utilization Review Manager is responsible for the development, management, and performance of the Utilization Review operation, and for ensuring the medical treatment provided to injured workers is effective, efficient, and in accordance with applicable legal requirements.
ESSENTIAL RESPONSIBILITIES AND PRINCIPAL ACCOUNTABILITIES
Denotes "essential functions" in accordance with the guidelines of The Americans with Disabilities Act. The essential functions of this position include, but are not necessarily limited to, those specifically identified in this description. The position and its essential functions may change over time and these changes may not necessarily be reflected in the position description. The Company may, at its sole discretion, add to, change, or expand the essential or marginal functions of the position.
- Manage the Company’s Utilization Review operation.
- Develop, administer, and manage effective and efficient work processes and communication within Utilization Review, with Medical Bill Review, with Nursing Services, with the adjusting staff, with other units of the Claims operation, and with other units of the Company.
- Ensure that utilization review is performed in compliance with Company policies, certification standards, and state and federal statutes and regulations.
- Maintain patient confidentiality and safeguard protected health information in accordance with state and federal laws and Company policies.
- Maintain the highest level of expertise regarding treatment guidelines and workers compensation utilization review including current issues, future developments, best practices, certification standards, and legal requirements.
- Foster a positive and close working relationship with other Company staff, including the adjusting staff, medical bill review, nurse case management, special investigations, legal, liens, the call center, and client services.
- Actively reinforce and support Company programs and initiatives including internal audit, training, and strategic and tactical innovation and improvement.
- Foster and guide the personal and professional development and growth of individual Utilization Review employees of varying levels of experience to help them build successful and satisfying careers while producing excellent results in their work and exhibiting exemplary workplace behavior.
- Provide information and support regarding medical treatment and utilization review in general and regarding specific claims to other Company employees including examiners, attorneys, lien representatives, case management coordinators, and special investigations staff.
- Analyze industry data and Company data and performance to identify opportunities for improvement and develop initiatives to meet those opportunities.
- Assist in the creation of technical and procedural training programs relating to utilization review to employees of the utilization review unit and other Company employees.
- Advise senior management on initiatives, programs, policies, and standards relating to utilization review.
- Communicate effectively and appropriately regarding utilization review issues with individuals outside the company.
- Serve as a role model for the Company’s culture by embodying the highest standards of collaboration, leadership, performance, behavior, and ethical standards.
- Leadership and Management: Inspires superb performance. Ensures that work processes and Company rules are followed. Creates and maintains a positive, motivated work environment. Prevents or promptly corrects behavioral problems. Demonstrates warmth, support, and understanding as well as strength, persistence, and high standards. Ability to manage medical personnel including nurses.
- Ethics: Demonstrates sound personal and professional character including candor, honesty, professional behavior, and a positive attitude. Promptly brings any errors, adverse results, or other issues of concern to the attention of the supervisor.
- Teamwork: Builds strong bonds of communication, cooperation, and mutual respect with other managers; participates with other members of the leadership team in supporting the continued improvement of the Company as a whole.
- Judgment: Displays confidence and willingness to make difficult decisions. Exhibits sound and accurate judgment. Supports and explains reasoning for decisions. Includes appropriate people in decision-making process. Makes timely decisions.
- Analysis: Synthesizes complex or diverse information including technical information relating to workers compensation claims, workers compensation premiums, medical practice, insurance law, and criminal law and procedure. Collects and understands data. Uses intuition and experience to complement data.
- Customer Relations: Provides effective communication with customers. Appropriately responds to and resolves complex situations or problems. Responds promptly to customer inquiries. Meets commitments.
- Responsibility: Take ownership of results. Possesses internal motivation and quality standard. Works to achieve outcomes while adhering to process standards.
- Problem Solving: Gathers and analyzes information skillfully and provides solutions in complex situations. Identifies items requiring additional information or action.
- Quality: Ensures staff works to a high level of accuracy and thoroughness when performing work processes. Applies feedback to improve performance. Monitors own work to ensure quality.
- Quantity: Ensures that staff meets productivity standards. Completes work in a timely manner. Strives to increase productivity. Works quickly.
- Written Communication: Prepares clear written text on complex technical matters in terms that will be understood by the recipient of the document.
- Oral Communication: Speaks clearly when explaining complex technical matters. Asks questions freely to broaden knowledge and skills. Listens and gets clarification. Responds well to questions. Participates in meetings in an open and interactive manner.
- Professionalism: Approaches others in a tactful manner. Reacts well under pressure. Treats others with respect and consideration regardless of their status or position. Accepts responsibility for own actions. Follows through on commitments.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit at a desk entering information into a computer and reading information presented on a computer monitor and on paper. The employee is also required to talk and hear on the telephone and in direct conversation. The employee will occasionally lift and move up to 10 pounds.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability generally required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Experience, Education, and Certification: Bachelor of Science Nursing degree (BSN); or Registered Nursing degree (RN) with an active license is advantageous; or a bachelor’s or master’s degree in a field relating to the business of medicine, including managing medical operations and personnel, is strongly preferred.
- Language Ability: Able to read, analyze, and interpret common scientific and technical journals, statues, regulations, medical reports, medical coding, medical bills, financial reports, and legal documents. Able to respond to technical inquiries or complaints from Company employees, external sources, and regulatory or auditing entities. Able to effectively present information and respond to questions with managers, clients, claimants, attorneys, medical providers, and others. Able to write clear, effective correspondence on complex medical issues to people from all walks of life.
- Math Ability: Able to calculate figures and amounts such as discounts, interest, proportions, percentages, sums, differences, products, and volumes.
- Reasoning Ability: Able to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Able to deal with problems involving several concrete variables in standardized situations.
- Technical Skills: Knowledge of current recognized evidence based medicine guidelines, office operations, workflow analysis, and current technologies in telecommunications, data entry, and file management.
- Computer Skills: Knowledge of Microsoft Office software. Able to quickly master proprietary and vended software applications.
BHHC - 4 months ago