Manager Utilization Review/Case Management CMC - Carole Young

UTMB Health•Galveston, TX

8d•Onsite

About The Position

Correctional Managed Care’s mission is to address the healthcare needs of underserved patient populations within the Texas Department of Criminal Justice and the Texas Juvenile Justice Department. The Manager of Utilization Review is responsible for daily department operations and manages Utilization Review Case Managers to support effective department operations, exceptional customer service, and patient support. The manager oversees the Utilization Review program to promote high-quality, cost-effective outcomes and a safe, efficient work environment. The position monitors staff performance, provides guidance, prepares work schedules and timekeeping, ensures adequate coverage, supports telephone utilization review as needed, and promotes teamwork. The manager also supports policy and procedure implementation, develops operational resources, and oversees new-personnel orientation and integration. The role serves as an expert resource on clinical resources and guidelines, reviews quality-of-care concerns and potential medical liability, contributes to department success and performance improvement, and follows established internal controls and reporting structures. The position reports to the Director, CMC Utilization Review, and supervises Utilization Review Case Managers.

Requirements

Graduate from an accredited school of professional nursing.
Hold a current, active, and valid Texas nursing license as a professional registered nurse.
At least five years of full-time, wage-earning experience as a professional nurse in a healthcare setting.
At least two years of utilization review and/or case management experience.
At least two years of supervisory and/or management experience.
Remain current on job-related knowledge, skills, and applicable in-service or certification requirements.
Demonstrate initiative and willingness and ability to learn multiple aspects of the job.
Demonstrate collaboration, professionalism, and ability to work with healthcare providers and staff.
Demonstrate support for the department as an active participant and leader.
Manage crisis situations professionally and effectively.
Prioritize work effectively.
Communicate clinical issues effectively to non-nursing utilization review staff.
Be willing to perform a variety of marginal clerical duties as needed.
Meet security clearance requirements; pre-employment drug testing is required.

Nice To Haves

Master’s degree.
At least three years of adult-care nursing experience.

Responsibilities

Supervise operational management of the Utilization Review program to ensure high-quality, cost-effective service and outcomes and a safe, efficient work environment.
Monitor Utilization Review Case Manager performance and provide guidance or intervention to help staff achieve department and individual goals.
Prepare department work schedules and manage timekeeping, ensuring adequate staff coverage and completion of work.
Provide backup support for telephone utilization review as needed to ensure adequate coverage.
Provide department leadership and promote teamwork.
Assist with implementation of Utilization Review policies and procedures.
Help identify needed standard operating procedures, flow diagrams, and job aids.
Orient new personnel and integrate them into the department as fully trained Utilization Review Case Managers.
Serve as an expert resource for clinical resources, including Optum (InterQual) and Urgent Referral guidelines, as well as other resources defined by Correctional Managed Care.
Review quality-of-care issues arising during department duties and identify potential medical-liability concerns.
Contribute to the overall success of UTMB Correctional Managed Care.
Adhere to department-established internal controls and reporting structures.
Participate in performance improvement and lead efforts to achieve department goals.
Perform other related duties as required.