Manager Utilization Review - FT - Day - Utilization Resource Mgmt Trenton NJ

Capital Health (US)

10d•$97,947 - $127,982•Onsite

About The Position

Performs a variety of utilization review activities to promote quality, clinical and cost-effective outcomes, including evaluation of length of stay and resource consumption. Manages activities of assigned staff in the process of providing utilization review. Plans, assigns, reviews and evaluates the work of assigned staff to achieve quality patient care, to operate in a fiscally responsible manner, to achieve operational efficiency and to adhere to established policies, practices, and procedures. Identifies opportunities and takes a leadership role in departmental performance improvement activities.

Requirements

Bachelor of Science in Nursing (BSN). An Associate Degree in Nursing (ADN) and additional years of experience may be considered in lieu of a BSN.
Four years of experience in nursing, including experience in the case management field in utilization review, discharge planning, outcomes management, assessment, care planning and/or care coordination when accompanied by a BSN.
Six years of experience in nursing, including experience in the case management field in utilization review, discharge planning, outcomes management, assessment, care planning and/or care coordination when accompanied by an ADN.
Registered Nurse - NJ
Excellent interpersonal, communication and negotiation skills with ability to convey understanding of complex issues.
Ability to interpret a variety of instructions furnished in written or oral form.
Strong organizational and time management skills.
Strong leadership, motivational and team building skills.
Analytical and data management skills.

Responsibilities

Performs all daily Utilization Review Functions, includes communicates with payers, performs clinical reviews utilizing the appropriate guidelines, policies, and timelines.
Identifies, develops, and implements strategies to facilitate appropriate length of stay and resource consumption.
Supervises utilization review staff to ensure that appropriate processes are followed according to CH policy and utilization guidelines.
Ensures equitable distribution of work assignment on a daily basis.
Adjusts work assignments throughout shift as needed.
Accepts staff call-outs and arranges alternate staffing as appropriate.
Ensures that appropriate staffing level are maintained through proactive planning.
Conducts routine reviews of utilization staff work product including reviews, payer correspondence, and resource management documentation to identify opportunities to enhance compliance with documentation requirements.
Provides ongoing feedback to utilization review director regarding department performance.
Acts as liaison with the administrative staff to handle any problems that arise.
Advises director when physician or patient issues require legal, ethical, or administrative interventions.
Attends system level meetings and represents utilization review services in order to promote and develop good working relationships.
Participates in system wide committees as assigned, such participation should also enhance knowledge of and about UR.
Provides for effective function of department by interviewing, hiring and training new utilization management staff.
Provides for ongoing function of department by assessing educational needs and providing training and ongoing mentoring to the utilization staff.
Conducts performance appraisals, manages the reward and discipline process and addresses complaints and resolves problems within the utilization management department.
Participates in performance improvement projects
Participates in DNV and other regulatory compliance activities.
Maintains and enhances relationships with internal and external customers and peers across the system in order to achieve excellent working relationships.
Assures that established outcome measures are met and that continuous quality improvement approach is in place for all utilization review.