Centralized Utilization Review Manager

Houston Methodist•Katy, TX

About The Position

Centralized Utilization Review Manager FLSA STATUS Exempt QUALIFICATIONS EDUCATION Bachelor’s degree or higher from an accredited school of Nursing Master’s degree in nursing preferred EXPERIENCE Five years' experience in inpatient case management, social work or utilization management or in the managed care/payer environment, of which one year must have been in a people management role in healthcare; for HM candidates, four years' experience in case management or social work, which includes HM performance that demonstrates progressive leadership abilities LICENSES AND CERTIFICATIONS Required RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency) and Magnet ANCC-recognized Case Management Certification: ACHPN-HPCC or ACM-NBCM or CCM-CCMC or CDCES-CBDCE or CHPN-HPCC or CMC-NACCM or CMCN-ABMCN or CMGT-BC-ANCC or COHN-ABOHN or COHN/CM-ABOHN or CPHRM-AHA-CC or RN-BC-ANCC SKILLS AND ABILITIES Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security Ability to effectively communicate through a variety of channels with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles; engages the recipient(s) and helps them understand and retain the message Demonstrates the ability to interact with others in a way that gives them confidence in one’s intentions and those of the organization Ability to use appropriate interpersonal styles and techniques to gain acceptance of ideas or plans; modifying one’s own behavior to accommodate tasks, situations and individuals involved Demonstrates leadership qualities and critical thinking through self-direction initiative and effective interpersonal skills and oral/written communication skills Ability to identify and understand issues, problems and opportunities, comparing data from different sources to draw conclusions; using effective approaches for choosing a course of action or developing appropriate solutions; taking action that is consistent with available facts, constraints and probable consequences Ability to work effectively in a fast paced environment Demonstrates flexibility and adaptability in the workplace Excellent analytical skills Advanced negotiation and mediation skills Advanced time management and prioritization skills Expert collaboration skills Advanced electronic medical record skills and data reporting skills MCG certification within one year of hire/transfer ESSENTIAL FUNCTIONS PEOPLE ESSENTIAL FUNCTIONS Performs management responsibilities of selection, scheduling, supervision, retention, and evaluation of employees in the department. Provides development and mentoring of staff. Meets or exceeds threshold goal for department turnover. Develops direct reports to perform these same functions. Provides fair and consistent leadership and communication to maintain a competent and engaged employee group by conducting regular department meetings to review policies and procedures and operational matters, rounding on all employees, completing performance appraisals, conducting new hire feedback sessions, coaching/corrective counseling, and providing recognition/commendations to achieve desired outcomes. Provides timely guidance and feedback to help others strengthen specific knowledge/skill areas needed to accomplish a task or solve a problem. Facilitates and promotes effective team dynamics and teambuilding strategies within and between departments; participates and/or leads and facilitates department process improvements as needed. Meets or exceeds threshold goal for department and/or system metrics on employee engagement indicators. Provides leadership to ensure operational effectiveness and efficiency of admission, concurrent and retrospective utilization management and medical claims functions to meet and exceed service-level goals and contract requirements. Serves as a liaison to physicians, case management, payers and other stakeholders. Responds to and resolves operational concerns related to utilization review processes. Maintains ongoing interactions with physicians and staff on how to improve documentation to support medical necessity, and denials prevention. Partners with physician advisors to support appeals, payer communications, and medical necessity reviews. SERVICE ESSENTIAL FUNCTIONS Plans and organizes day-to-day department operations, schedule and activities. Sets priorities and functional standards, giving direction to staff as necessary to ensure the best possible delivery of service and high customer/patient satisfaction. Drives department service standards and activities to impact department and/or system score for patient/customer-based satisfaction, through role modeling and fostering accountability. Serves and actively participates on various entity committees as a voice for the department. Makes and executes decisions within delegated authority. Escalates issues to management for resolution as appropriate. Participates in resolving issues outside delegated scope of authority. Oversees work queue management to ensure performance targets and service-level agreements are met. Supports maximization of UR system utilization, including length of stay (LOS), readmissions, and other KPIs as set by the organization. Supports hospital UM Committees as needed. Strategizes and negotiates with the interprofessional team, patient and family, providers and payors about the care provided and the best course of action. QUALITY/SAFETY ESSENTIAL FUNCTIONS Ensures a safe and effective working environment; monitors and/or revises the department safety plan and/or any specific accreditation/regulatory required safety guidelines, including infection control principles. Monitors and confirms staff maintain their required credentials that demonstrate competency per accrediting agency or department guidelines as applicable. Uses and optimizes information systems to enhance operations; supports entity-specific performance improvement and data management/analysis functions. Employs a proactive approach in the optimization of safe outcomes by monitoring and improving the department workflow, using peer-to-peer accountability, reporting accidents, near misses, and/or adverse events immediately per department protocol and identifying solutions via collaboration. Adopts LEAN principles in driving process improvements. Role models situational awareness, using teachable moments to improve safety. Monitors self and employee compliance with policies, procedures, and System HR Standards of Practice and performs associated actions upon non-compliance (i.e., focal point review requirements, disaster plan, inservices, influenza immunization, wage and hour, standard hours, timely termination submission, timely timecard approval, etc.). Supports maximization of Case Mgmt. system utilization, including length of stay (LOS), readmissions, and other KPIs as set by the organization. 5. Ensures UR operations comply with CMS Conditions of Participation, DNV, state regulatory requirements, and payer standards. Oversees the timely and accurate issuance of required notices in collaboration with case management (MOON, IMM, ABN, HINN, CC44, MCSN). Generates reports to identify trends and opportunities for process improvement. Develops audit reports to identify quality issues and areas for enhanced staff training. Provides education to clinical and operational teams on level-of-care criteria and documentation requirements. Oversees the quality assurance and quality improvement processes related to admission, concurrent and retrospective UM and medical claims programs. Collaborates with medical and clinical leadership to implement new processes for enhancing service levels. Identifies opportunities to streamline UR workflows and improve efficiency through technology and process improvement. FINANCE ESSENTIAL FUNCTIONS Assists in the development of department budget and ensures that the department operates in a cost-effective manner. Manages/audits department expenses within approved budget parameters, ensuring that the department meets the budgeted/flex revenue and/or expense targets on a monthly and annual basis. Develops staffing plans and schedules to meet department/patient needs that reflect understanding of the importance of cost-effectiveness. Implements department strategies to achieve financial target and staffing needs, developing others to do the same, through optimizing productivity, supply/resource efficiency, minimizing incidental overtime and overtime percentage, and other areas according to department specifications. Manages utilization management (UM) programs including Medical Claims Review, Precertification and Reconsiderations and Appeals. Supports revenue integrity through timely work que management by minimizing avoidable days, denials, and delays in billing. Maintains compliance with Medicare short-stay reviews and notices. Ensures adequate staffing and coverage for all UR and denials team functions across all shifts. Collaborates with revenue cycle and managed care contracting teams to align UR processes. Monitors and reports on denial trends, Candidate for Billing (CFB) accounts, and other financial metrics. GROWTH/INNOVATION ESSENTIAL FUNCTIONS Identifies and implements innovative solutions for practice or workflow changes to improve department operations or other department-specific measures by leading unit projects and/or other department/system directed/shared governance activities. Supports change initiatives, maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusts effectively to work within new work structures, processes, requirements or cultures. Proactively evaluates processes; recommends and implements action plan(s) for change; follows through to ensure effective, sustainable change. Participates in the development and implementation of new procedures and the review and revision of existing procedures. Identifies opportunities and takes action to build strategic relationships between one’s area and other areas, teams, departments, and units to achieve business goals. Seeks opportunities to identify developmental needs of self and staff and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates My Development Plan (MDP) on an ongoing basis. Conducts conversations with staff on their development. Recommends appropriate uses for the UR system, coordinating initial training for new users and ongoing training department staff of system upgrades, changes, and new functions as necessary. Participates in system initiatives to integrate technology platforms and automate UR processes where appropriate.

Requirements

Bachelor’s degree or higher from an accredited school of Nursing
Five years' experience in inpatient case management, social work or utilization management or in the managed care/payer environment, of which one year must have been in a people management role in healthcare; for HM candidates, four years' experience in case management or social work, which includes HM performance that demonstrates progressive leadership abilities
RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)
Magnet ANCC-recognized Case Management Certification: ACHPN-HPCC or ACM-NBCM or CCM-CCMC or CDCES-CBDCE or CHPN-HPCC or CMC-NACCM or CMCN-ABMCN or CMGT-BC-ANCC or COHN-ABOHN or COHN/CM-ABOHN or CPHRM-AHA-CC or RN-BC-ANCC
Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations
Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
Ability to effectively communicate through a variety of channels with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles; engages the recipient(s) and helps them understand and retain the message
Demonstrates the ability to interact with others in a way that gives them confidence in one’s intentions and those of the organization
Ability to use appropriate interpersonal styles and techniques to gain acceptance of ideas or plans; modifying one’s own behavior to accommodate tasks, situations and individuals involved
Demonstrates leadership qualities and critical thinking through self-direction initiative and effective interpersonal skills and oral/written communication skills
Ability to identify and understand issues, problems and opportunities, comparing data from different sources to draw conclusions; using effective approaches for choosing a course of action or developing appropriate solutions; taking action that is consistent with available facts, constraints and probable consequences
Ability to work effectively in a fast paced environment
Demonstrates flexibility and adaptability in the workplace
Excellent analytical skills
Advanced negotiation and mediation skills
Advanced time management and prioritization skills
Expert collaboration skills
Advanced electronic medical record skills and data reporting skills
MCG certification within one year of hire/transfer

Nice To Haves

Master’s degree in nursing preferred

Responsibilities

Performs management responsibilities of selection, scheduling, supervision, retention, and evaluation of employees in the department.
Provides development and mentoring of staff.
Meets or exceeds threshold goal for department turnover.
Develops direct reports to perform these same functions.
Provides fair and consistent leadership and communication to maintain a competent and engaged employee group by conducting regular department meetings to review policies and procedures and operational matters, rounding on all employees, completing performance appraisals, conducting new hire feedback sessions, coaching/corrective counseling, and providing recognition/commendations to achieve desired outcomes.
Provides timely guidance and feedback to help others strengthen specific knowledge/skill areas needed to accomplish a task or solve a problem.
Facilitates and promotes effective team dynamics and teambuilding strategies within and between departments; participates and/or leads and facilitates department process improvements as needed.
Meets or exceeds threshold goal for department and/or system metrics on employee engagement indicators.
Provides leadership to ensure operational effectiveness and efficiency of admission, concurrent and retrospective utilization management and medical claims functions to meet and exceed service-level goals and contract requirements.
Serves as a liaison to physicians, case management, payers and other stakeholders.
Responds to and resolves operational concerns related to utilization review processes.
Maintains ongoing interactions with physicians and staff on how to improve documentation to support medical necessity, and denials prevention.
Partners with physician advisors to support appeals, payer communications, and medical necessity reviews.
Plans and organizes day-to-day department operations, schedule and activities.
Sets priorities and functional standards, giving direction to staff as necessary to ensure the best possible delivery of service and high customer/patient satisfaction.
Drives department service standards and activities to impact department and/or system score for patient/customer-based satisfaction, through role modeling and fostering accountability.
Serves and actively participates on various entity committees as a voice for the department.
Makes and executes decisions within delegated authority.
Escalates issues to management for resolution as appropriate.
Participates in resolving issues outside delegated scope of authority.
Oversees work queue management to ensure performance targets and service-level agreements are met.
Supports maximization of UR system utilization, including length of stay (LOS), readmissions, and other KPIs as set by the organization.
Supports hospital UM Committees as needed.
Strategizes and negotiates with the interprofessional team, patient and family, providers and payors about the care provided and the best course of action.
Ensures a safe and effective working environment; monitors and/or revises the department safety plan and/or any specific accreditation/regulatory required safety guidelines, including infection control principles.
Monitors and confirms staff maintain their required credentials that demonstrate competency per accrediting agency or department guidelines as applicable.
Uses and optimizes information systems to enhance operations; supports entity-specific performance improvement and data management/analysis functions.
Employs a proactive approach in the optimization of safe outcomes by monitoring and improving the department workflow, using peer-to-peer accountability, reporting accidents, near misses, and/or adverse events immediately per department protocol and identifying solutions via collaboration.
Adopts LEAN principles in driving process improvements.
Role models situational awareness, using teachable moments to improve safety.
Monitors self and employee compliance with policies, procedures, and System HR Standards of Practice and performs associated actions upon non-compliance (i.e., focal point review requirements, disaster plan, inservices, influenza immunization, wage and hour, standard hours, timely termination submission, timely timecard approval, etc.).
Supports maximization of Case Mgmt. system utilization, including length of stay (LOS), readmissions, and other KPIs as set by the organization.
Ensures UR operations comply with CMS Conditions of Participation, DNV, state regulatory requirements, and payer standards.
Oversees the timely and accurate issuance of required notices in collaboration with case management (MOON, IMM, ABN, HINN, CC44, MCSN).
Generates reports to identify trends and opportunities for process improvement.
Develops audit reports to identify quality issues and areas for enhanced staff training.
Provides education to clinical and operational teams on level-of-care criteria and documentation requirements.
Oversees the quality assurance and quality improvement processes related to admission, concurrent and retrospective UM and medical claims programs.
Collaborates with medical and clinical leadership to implement new processes for enhancing service levels.
Identifies opportunities to streamline UR workflows and improve efficiency through technology and process improvement.
Assists in the development of department budget and ensures that the department operates in a cost-effective manner.
Manages/audits department expenses within approved budget parameters, ensuring that the department meets the budgeted/flex revenue and/or expense targets on a monthly and annual basis.
Develops staffing plans and schedules to meet department/patient needs that reflect understanding of the importance of cost-effectiveness.
Implements department strategies to achieve financial target and staffing needs, developing others to do the same, through optimizing productivity, supply/resource efficiency, minimizing incidental overtime and overtime percentage, and other areas according to department specifications.
Manages utilization management (UM) programs including Medical Claims Review, Precertification and Reconsiderations and Appeals.
Supports revenue integrity through timely work que management by minimizing avoidable days, denials, and delays in billing.
Maintains compliance with Medicare short-stay reviews and notices.
Ensures adequate staffing and coverage for all UR and denials team functions across all shifts.
Collaborates with revenue cycle and managed care contracting teams to align UR processes.
Monitors and reports on denial trends, Candidate for Billing (CFB) accounts, and other financial metrics.
Identifies and implements innovative solutions for practice or workflow changes to improve department operations or other department-specific measures by leading unit projects and/or other department/system directed/shared governance activities.
Supports change initiatives, maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusts effectively to work within new work structures, processes, requirements or cultures.
Proactively evaluates processes; recommends and implements action plan(s) for change; follows through to ensure effective, sustainable change.
Participates in the development and implementation of new procedures and the review and revision of existing procedures.
Identifies opportunities and takes action to build strategic relationships between one’s area and other areas, teams, departments, and units to achieve business goals.
Seeks opportunities to identify developmental needs of self and staff and takes appropriate action.
Ensures own career discussions occur with appropriate management.
Completes and updates My Development Plan (MDP) on an ongoing basis.
Conducts conversations with staff on their development.
Recommends appropriate uses for the UR system, coordinating initial training for new users and ongoing training department staff of system upgrades, changes, and new functions as necessary.
Participates in system initiatives to integrate technology platforms and automate UR processes where appropriate.