About the position
The Manager of Utilization Management (MUM) is a key member of the integrated community care team (ICCT) at AbsoluteCare, providing clinical and performance oversight of a transitional care management team comprised of registered nurses. The MUM understands the level of care and medical necessity process, discharge planning, care coordination, and integrated case management supports for members currently admitted at an inpatient facility. This role involves close collaboration with the center medical director and the Program Manager of Utilization Management to identify and implement integrated processes to improve outcomes. The MUM is responsible for the oversight of daily operations of the utilization management and transitional care management team, ensuring compliance with internal and NCQA timeliness and care plan/documentation standards, conducting case file/performance reviews, and participating in interdisciplinary care team meetings and rounds. The MUM leads team meetings and maintains team morale through virtual and in-person activities, and is responsible for interviewing, hiring, and ensuring onboarding/training needs are met for new hires. Effectiveness is measured by value-based care outcomes including member engagement, admission and readmission rates, length of stay, bed days, and hospital follow-up completion rates.
Responsibilities
- Lead a transitional care team comprised of licensed clinical staff and/or unlicensed staff/peer supports.
- Develop payor and facility relationships with leadership and case management departments for collaborative member management at time of inpatient stays and during care transitions.
- Facilitate rounding with payor and facilities to review and problem solve for members at risk for unnecessary or avoidable utilization.
- Leverage evidenced based guidelines such as MCG or InterQual for discharge planning and optimize appropriate level of care decisions.
- Closely collaborate with community and center-based colleagues to deliver integrated care under a collaborative care model through interdisciplinary care team meetings, case consultations, etc.
- Use daily operational reports to monitor team performance and proactively identify low performing staff and/or processes requiring improvements.
- Proactively identify low performing staff and implement coaching and/or performance improvement plans to meet performance/quality standards.
- Oversee clinical staff development and performance that results in person-centered care planning, SMART goals, clear and consistent documentation, use of evidence-based disease management and chronic care protocols.
- Oversee all caseloads assigned to the transitional care management team to ensure member follow up, timely and accurate documentation, and compliance with company, health plan, and NCQA requirements.
- Serve as a Subject Matter Expert (SME) on transitional care and utilization management and lead the training and adoption of these approaches to member care for the assigned market.
- Host regular 1:1 meetings and team meetings with all direct reports and maintain related documentation.
- Interview, hire, and complete departmental onboarding/preceptorships for new employees in coordination with the Manager of Utilization Management.
- Proactively identify and mitigate barriers to team productivity and member care through data analysis, creative problem solving, and process optimization.
- Meet deadlines and manage competing priorities.
- Maintain the security and privacy of all information that is owned by AbsoluteCare or maintained on behalf of the company's patients, employees, and business partners.
Requirements
- Must be willing and able to travel up to 80% of the time to local area hospitals, skilled nursing facilities and residential treatment facilities.
- Licensed RN by the state in which practicing and abide by all laws, regulations, and requirements.
- Preference given to RN candidates with extensive experience in discharge planning, care transition coordination, and medical and behavioral case management in the community.
- Candidate with CCM or CCTM credentials a plus.
- 2 years of management experience preferred.
- 4 years of supervisory experience considered.
- 5 years experience in discharge planning and care coordination for continuity in care transitions.
- Experience serving the needs of complex populations, including medically complex, trauma history, mental health conditions, substance abuse, and socioeconomic barriers.
- Experience with complex government-sponsored populations preferred, e.g., Medicaid, Medicare beneficiaries.
- Experience with member engagement, transitions of care, clinical care, and/or case management.
- Experienced in concurrent review for level of care determinations.
- Excellent computer skills including Microsoft Office Suite and electronic medical record documentation required.
- Excellent written and oral communication skills to interact with members, families, community stakeholders, and interdisciplinary team required.
- Ability to meet accreditation and quality standards including NCQA, PCMH, HEDIS.
- Good leadership skills with proven record of developing and maintaining team morale.
- Ability to work independently and exercise excellent clinical judgement.
- Active unencumbered driver's license, with automobile insurance, reliable transportation.
- Excellent organizational and time management skills to prioritize and meet deadlines.
- Ability to analyze data to identify and implement process improvements.
- Proven record of ability to lead through change in a dynamic environment.
- Active CPR certification.
Nice-to-haves
- Experience with multiple settings (Inpatient, LTPAC, home health, corrections, community programs and/or human service agencies).
