Manager - Utilization Review

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 required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties.

This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at the company's discretion.

Education

Required -Bachelors degree in nursing (BSN)

OR

Master's degree in social work (MSW).

Work Experience

Required -3 yearsof case management experience in an acute care setting or similar environment.

Experience in compliance management systems (CMS) regulations, compliance and quality metrics.

Experience managing denials and appeals of all payer cases in a timely and organized manner.

Preferred - 1 year of management level experience.

Experience in managed care, quality management, regulatory compliance, medical management, or other related MCO departments/functions.

Certifications

Required -Current registered nurse (RN) license in state of practice.

*MSW accepted in lieu of registered nurse (RN) licensure.

Preferred - Certification in Case Management (CCM) or Certified Professional in Healthcare Management (CPHM).

Knowledge Skills and Abilities (KSAs)

• Proficiency in using computers, software, and web-based applications.

• Effective verbal and written communication skills and ability to present information clearly and professionally to varying levels of individuals throughout the patient care process.

• Conflict resolution skills and ability to demonstrate good judgement in performing duties.

• Knowledge of business management principles including operations, finance, audit, authorizations, referrals, discharge planning, personnel, and resource management.

• Understanding of financial statements and ability to manage within a budget, analyze trends, and make recommendations.

• Must be able to work a flexible work schedule (e.g. 24/7, weekend, holiday, on call availability)

Job Duties

• Leads respective teams with high motivation and responsibility for the welfare of the entire team making decisions based on good judgement rather than popularity.

• Promotes, supports, encourages, and fosters maximum communication across case management with the purpose of making one accessible and available to all team members ensuring that effective problem analysis is exercised across all levels of the organization.

• Conducts personal leadership self-development with the conscious intention to always become a better, more effective leader.

• Manages the implementation controls for all precertification, continued stay, authorization and billing processes as well as policies and procedures required for success under the direction of the case management leadership.

• Leads special and audit projects independently with the end goal of ensuring that the internal control environment is not compromised and the awareness of the process control culture is increasingly heightened.

• Determines appropriate staffing levels and the interviewing, hiring, performance review, and termination of employees within practice unit(s); maintains employee schedules to assure appropriate coverage.

• Develops departmental specific systems to assure an environment that emphasizes patient courtesy and responsive service delivery.

• Performs other related duties as required.

The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time.
Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards.

This employer maintains and complies with its Compliance & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns.
The employer is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status.

Physical and Environmental Demands
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.

Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. NOTE: The constant stress and strain of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is negligible.

Normal routine involves no exposure to blood, body fluid or tissue and as part of their employment, incumbents are not called upon to perform or assist in emergency care or first aid.
There is no occupational risk for exposure to communicable diseases

Because the incumbent works within a healthcare setting, there may be occupational risk for exposure to hazardous medications or hazardous waste within the environment through receipt, transport, storage, preparation, dispensing, administration, cleaning and/or disposal of contaminated waste. The risk level of exposure may increase depending on the essential job duties of the role.

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