Registered Nurse-Manager of Utilization Management, Full Time Days

Cape Fear Valley Health

3d•Onsite

About The Position

The Registered Nurse-Manager of Utilization Management oversees operational and personnel activities related to Utilization Management. The role coordinates and manages denials and outgoing appeals between payers and Cape Fear Valley Health System, and supports collaboration among community, health system, physician, and support staff to promote effective management and cost containment of patient care across the healthcare continuum. The manager fosters teamwork and integrated services for Coordination of Care staff and customers, adheres to patient experience initiatives, and champions customer service excellence. The position leads Utilization Management RNs, reviews policies and procedures, monitors regulatory changes, audits admission and concurrent reviews, and educates staff based on analysis of data and trends. It responds to payer demand letters and appeal deadlines, serves as a Medical Necessity Reviewer with the Physician Advisor for the Recovery Audit Contractor Team, and supports Joint Commission compliance. The manager also develops audit tools and improvement strategies to meet the needs of patient populations, the hospital, and the community. The role requires working every fourth or fifth weekend. Relocation assistance is available.

Requirements

Associate’s degree in Nursing.
Current Registered Nurse licensure in North Carolina or compact state licensure.
At least 3 years of Utilization Management experience.
Management experience in Utilization Review and experience with insurance claims.
Understanding of revenue cycle operations.
Understanding of Epic and Epic reporting, including the ability to build reports to manage staff and improve an existing UM committee.
Proficiency in reading, writing, and speaking English.
Knowledge of professional nursing principles, clinical processes, and clinical interventions.
Working knowledge of Medicare guidelines relevant to inpatient hospital and ambulatory services.
Ability to review medical records and interpret, abstract, aggregate, analyze, and report complex clinical data.
Knowledge of clinical practice guidelines and appropriateness of clinical interventions.
Knowledge and ability to implement a quality improvement process.
Strong analytical, data management, and research skills.
Excellent interpersonal communication and negotiation skills; ability to communicate and work effectively with people from varied social, economic, and cultural backgrounds.
Self-motivation and proven written, telephone, and electronic communication skills.
Ability to interact assertively and persuasively with customers, peers, management, and core staff served.
Strong organizational and time-management skills, including the ability to prioritize multiple tasks and role components.
Understanding of criteria and measurement outcomes.
Knowledge of third-party payer requirements, including managed care, reimbursement, and utilization management.
Proficiency with Microsoft Office, EPIC, InterQual, MCG, Teams, and Webex.
Working knowledge of Coordination of Care, Medical Management, Utilization Review, Performance Improvement, and Criteria-Based Management.
Ability to demonstrate leadership, respect, and team building.
Flexibility, open-mindedness, and adaptability to change.
Ability to perform some light carrying and lifting and occasional walking to access areas of the Medical Center.
Ability to communicate orally with patients, family members, personnel, and physicians; near visual acuity to proofread materials; and manual ability to use telephones and a computer keyboard.
Ability to sit for extended periods while performing computer data entry.
Availability to work every fourth or fifth weekend.

Nice To Haves

Bachelor’s degree in Nursing.
One year of Case Management experience.
One year of experience with data and statistical analysis.
Three years in managed care claims/reimbursement or another healthcare field.

Responsibilities

Lead, coordinate, and oversee the workload of Utilization Management RNs.
Review and recommend policies and procedures related to Utilization Management.
Maintain knowledge of Medicare and Medicaid regulation changes, communicate updates, and facilitate process changes needed for compliance.
Audit staff Admission and Concurrent Reviews for accurate application of criteria.
Educate staff based on comprehensive analysis of data and identified trends.
Respond proactively to payer demand letters and ensure appeal deadlines are met.
Serve as Medical Necessity Reviewer in conjunction with the Physician Advisor for the Recovery Audit Contractor Team.
Educate staff on and facilitate compliance with Joint Commission requirements, audits, compliance, and record maintenance.
Develop department and individual performance audit tools to measure compliance and quality.
Identify opportunities, solutions, and strategies to improve Utilization Management processes for patient populations, the hospital, and the community.
Perform other duties as assigned.