Regional Supervisor of Utilization Review

Appalachian Regional Healthcare, Inc.•Lexington, KY

About The Position

The Regional Utilization Review Supervisor assists the Regional Director of Utilization Review with ensuring and supporting proper management and implementation of department policy and process. The Regional Supervisor provides clinical group leadership and expert technical guidance to the utilization review team. The incumbent in this role also promotes consistent application, effective processes and accountability.

Requirements

Registered nurse or LPN (licensed in state of employment) from an accredited School of Nursing.
Completion of two (2) years accredited Records Technician Program with two (2) years’ experience or completion of an accredited program and current credentialing in a health-related field.
Willing to obtain licensure in additional states, as needed, within 6 months of hire
Minimum of two (2) years’ experience in a managerial position in a clinical setting preferred.
Demonstrated ability to analyze, synthesize, report and manage patient care information typically obtained through previous experience in utilization review or case management.
Strong Professional, organizational, and interpersonal skills required for effective and creative leadership in working with all levels of the Organization including physicians, committees, senior management, trustees, patients and their families.
Ability to lead, support and build on current efforts of various groups working within the department’s scope of work.
Ability to extensively communicate effectively with outside agencies, third-party payors and regulators.
Function independently within the broad scope of department and organization-wide policies, practices and common goals.
In depth knowledge of InterQual Criteria Sets

Nice To Haves

Bachelor’s degree in nursing
Certified Case Manager

Responsibilities

Skills to effectively manage department workforce; determine staffing levels for your assigned services/staffing assignments and “flex” as needed based on daily census
Strong professional, organizational and interpersonal skills to effectively relate with all members of the healthcare team
Demonstrated ability to analyze, synthesize, report and manage patient care data obtained through previous quality/performance improvement activities
Knowledge of all functions of care management, i.e. utilization management, care management, social work concepts and importance of clinical documentation
Knowledge of utilization management process, discharge planning, care management, community resources, Medicare, Medicaid, other third-party payor and hospital payment systems. Requires skill to apply nationally accepted medical necessity criteria sets.
Provides structure and assure consistent implementation of the care management department policies and processes
Precepts new department staff managers.
Serves as resident care management “expert” to consistently support URCM needs for on-going education.
Assigns coverage for UR CM PTO/Open positions.
Assists with quality audits; Analyzes care management outcomes to identify issues and make recommendations.
Formulates, implements, and evaluates educational strategies for staff, patients and family.
Inputs into department staff performance evaluations or direct supervisory authority as determined by leadership.
Assists in the interviewing, hiring and termination of care management staff.
Issues in-house denials for extended length of stays
Serves on various hospital committees as required
Monitors length of stay on a concurrent, weekly, and monthly basis. Ensures that the length of stay is appropriate based on medical necessity. Works with medical staff, hospital staff and others to overcome barriers to discharge.
Maintains knowledge of applicable DNV standards and other regulatory agency requirements and works with leaders within the organization to maintain ongoing compliance.
Ability to develop and implement PI activities and ensure delivery of customer service