The Utilization Review Department Manager is responsible for assisting in the
development and evolution of the overall strategy for the company’s ongoing medical necessity review operations within Utilization Review Department/Case Management.
The UR Manager manages, directs, and coordinates the utilization review activities of the department.
Responsibilities include management of process and personnel.
The UR Manager plans, assigns, and directs workflow for the department, actively monitors employee performance and rewards or disciplines accordingly; addresses complaints and resolves problems; and actively oversees and manages production and quality control efforts.
Facilitates the interdisciplinary plan of care with a focus on evaluating the appropriateness of clinical care, medical necessity, admission status, level of care, and resource management. The UR Manager will coordinate activities that promote quality outcomes and patient throughput while supporting a balance of optimal care and appropriate resource utilization.
ESSENTIAL JOB RESPONSIBILITIES
- Provides direct managerial oversight to utilization review nurse in management of inpatient and outpatient medical necessity reviews, work processes and overall work responsibilities.
- Ensures complete, accurate, and timely medical necessity review while following established protocols, policies, and processes established by HCA policies.
- Responsible for operational activities relating to medical necessity review, documentation and patient throughput.
- Coaches and helps develop staff, helps resolve dysfunctional behavior within functional are(s); disciplines and counsels staff as necessary.
- Proactively manages significant issues related to utilization management, status of projects, barriers and successes.
- Responsible for review and improvement of processes and services
- Selects, evaluates, trains and provides leadership and direction to reporting staff.
- Evaluates medical necessity using approved criteria prior to admission; escalates medical necessity and admission status issues through the established chain of command timely.
- Evaluates and assess observation patients for appropriateness in observation status
- Acts as a liaison through effective and professional communications between and with physicians, patient / family, hospital staff, and outside agencies.
- Interacts effectively and professionally with physicians, patient/family, hospital staff, and outside agencies.
- Demonstrates knowledge of regulatory requirements, HCA Ethics and Compliance policies, and quality initiatives; monitors self-compliance and implements process changes to ensure compliance
to such regulations and quality initiatives as it relates to the provision of Utilization Review/Case Management Services.
- Tracks and trends variances to care and barriers to care;
makes recommendations and develops
action plans to improve processes and systems
- Adheres to established policy and procedure and standards of care;
escalates issues through the established Chain of Command timely
**This is not necessarily an extensive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job.
While this is intended to be an accurate reflection of the current job, management reserves the right to revise the job or require that other or different tasks be performed when circumstances change (i.e. emergencies, changes in personnel, workload, rush jobs or technical developments).
KNOWLEDGE, SKILLS AND ABILITIES
EDUCATION AND EXPERIENCE
- Ability to establish and maintain collaborative and effective working relationships
- Ability to communicate effectively in oral, written and electronic formats
- Demonstrates analytical and critical thinking abilities with pro-active decision-making and negotiation skills
- Demonstrates and ability to perform specific competencies as identified on the Case Manager Competency Grid
- Basic typing skills, 30 wpm;
- Basic personal computer skills;
- Positive, enthusiastic, helpful personality;
- Customer service oriented;
Graduation from an accredited school of nursing.
Three years nursing experience in acute care setting.
Case Management experience
Knowledge in applications of InterQual Care guideline.
LICENSES AND CERTIFICATES
Current license to practice as a Registered Nurse in Texas.
Certification in Case Management, Nursing, or Utilization Review.
Completion of or actively pursuing a BSN degree
HCA Inc - 17 months ago