Manager, Utilization Review

Tampa General Hospital•Tampa, FL

About The Position

Under the administrative supervision of the Director of Utilization Management, this role manages the daily activities of the Utilization Review Nurses and Case Management Extenders. The goal is to ensure effective processes and successful completion of utilization management, payer communication, authorizations for care provided, and timely progression of care and discharge planning. This position supports the efforts of HIM and Patient Accounts by ensuring timely, accurate, and complete data entry in multiple information systems and denials prevention and management. The Manager brings issues with legal, risk management, or ethical implication to the attention of the Director expediently. This role functions as a key contact point for the Hospital and maintains excellent working relationships with payers. The Manager participates in strategic planning for the department, working as a member of the case management leadership team. Responsibilities include interviewing applicants, making recommendations for hiring and salary for new employees, completing performance appraisals in a timely manner, and employing disciplinary actions as required. The Manager communicates with other departments in the hospital at a high level to ensure that information flow is timely, appropriate, and accurate. The role also represents the department on Committees as indicated and is responsible for performing job duties in accordance with the mission, vision, and values of Tampa General Hospital and the principles of quality improvement.

Requirements

Five (5) years of clinical experience
A minimum of five (5) years experience in utilization management and/or case management required
Licensed as a Registered Nurse in the state of Florida

Nice To Haves

May substitute for the degree

Responsibilities

Manages the daily activities of the Utilization Review Nurses and Case Management Extenders.
Ensures effective processes and successful completion of utilization management, payer communication, authorizations for care provided, and timely progression of care and discharge planning.
Supports HIM and Patient Accounts by ensuring timely, accurate, and complete data entry in multiple information systems and denials prevention and management.
Brings issues with legal, risk management, or ethical implication to the attention of Director in an expedient manner.
Functions as key contact point for Hospital and maintains excellent working relationships with payers.
Participates in strategic planning for the department, working as a member of the case management leadership team.
Interviews applicants, makes recommendations for hiring and salary for new employees, completes performance appraisals in a timely manner and employs disciplinary actions as required.
Communicates with other departments in the hospital at a high level to ensure that information flow is timely, appropriate and accurate.
Represents the department on Committees as indicated.
Responsible for performing job duties in accordance with the mission, vision, and values of Tampa General Hospital and the principles of quality improvement.
Develops the procedures required for an efficient, effective utilization review program.
Manages the implementation of the utilization review program and concomitant activities of the Utilization Review Nurses and Case Management Extenders in a fast paced, dynamic environment.
Maintains current knowledge of all local, state, and federal regulatory requirements related to care coordination responsibilities.
Has an in-depth understanding of utilization management guidelines used to evaluate patient care and status.
Leads and participates in departmental and organizational performance improvement activities including the utilization of variance and denial data to assist hospital leadership in identifying opportunities for improvement.
Develops effective processes to ensure accurate and timely admission and continued stay reviews, appropriate authorizations for care and quality communication with payers and caregivers.
Monitors, reports outcomes/patterns/trends; guides/supports Team Lead.
Assists Director with reporting and case presentations.
Participates in meetings per Director.
Identifies opportunities for UM Strategic planning.
Assesses the quality of work performed in the department, providing feedback to employees with the goal of continuous improvement.
Serves as a resource to staff to support, manage, and/or resolve issues related to utilization/denials management, and hospital admission authorization.
Completes necessary research to gather appropriate details/information prior to making decisions when complex issues are presented.
Submits staff performance management report, maintaining productivity at approved standards.
Oversees and guides operations towards efficiency, effectiveness.
Performance Appraisal/Competency of each staff member.
Determines remediation, education needs and performance action plans.
Guides the TL within determined scheduling parameters.
Establishes consistent practice with scheduling to maintain optimal staff/review coverage needs.
Collaborates closely with Case Management and Revenue Cycle to align with overall organizational action plans/goals.