Registered Nurse-Supervisor Utilization Management

Children's Hospital of Philadelphia•Worcester, MA

1d•$98,820 - $126,000•Onsite

About The Position

This position requires an RN with 3 years experience in acute care setting. It is 40 hours a week and is bonus eligible. It is Monday- Friday 8-4:30 or 8:30-5p. There is a weekend call 1 time a month. This Hiring Manager prefers a candidate with previous Case Management experience. Looking for a candidate who has taken on a project and has demonstrated the ability to translate complex information into operational aspects. Under the direction of the Manager, Utilization Management, the Supervisor Utilization Review (UR) oversees the development, implementation, and performance management of the Utilization Review and Denials Prevention program across all Children's Hospital of Philadelphia (CHOP) acute hospitals. This pivotal role entails managing utilization review and authorization management services to promote appropriate levels of care, length of stay, and prevention of payer denials. The supervisor consistently demonstrates the ICARE values of CHOP and serves as a role model to other employees.

Requirements

RN with 3 years experience in acute care setting.
Bachelor's Degree Business, Nursing, or Health Care Administration
At least three (3) years experience as a clinical nurse in an acute care setting.
At least five (5) years hospital or healthcare leadership
Excellent communication skills and demonstrated organizational skills.
Knowledge of payor contracts and regulatory requirements.
Ability to work effectively with all departments and all levels of CHOP professionals.
Ability to work independently or within a team structure.
Must be very organized and able to work independently.
Ability to establish priorities among multiple needs, meet deadlines and maintain productivity standards.
Knowledge of managed care admission process (i.e. verification of benefits, admissions notification).
Ability to effectively negotiate with internal and external providers of patient care services.
Sound problem-solving and analytical skills.
Excellent customer service orientation and strong interpersonal skills.
Computer skills and a working knowledge of Word, Excel and PowerPoint.
Registered Nurse (Pennsylvania) - Pennsylvania State Licensing Board - upon hire

Nice To Haves

Previous Case Management experience.
Candidate who has taken on a project and has demonstrated the ability to translate complex information into operational aspects.
Master's Degree Business, Nursing, or Health Care Administration
At least three (3) years Case Manager or Utilization Reviewer
At least three (3) years Case Management Leadership role
Certified Case Manager (CCM) - Commission for Case Manager Certification - upon hire

Responsibilities

Lead and manage the utilization management team, including recruitment, training, performance management, and coaching to ensure optimal team performance and productivity.
Oversee the utilization review process, including evaluating medical necessity, appropriateness of care, and compliance with clinical guidelines and policies.
Monitor and evaluate the quality and accuracy of utilization management decisions, ensuring compliance with regulatory requirements and accreditation standards.
Identify opportunities for process improvement and implement strategies to streamline workflows, enhance efficiency, and optimize utilization management practices.
Collaborate with internal stakeholders, including healthcare providers, care managers, and other departments, to facilitate effective communication and coordination of care.
Analyze utilization data, trends, and outcomes to identify areas for improvement and support decision-making processes.
Ensure compliance with relevant laws, regulations, and accreditation standards governing utilization management activities.
Develop and deliver training programs and educational materials to support staff development and ensure understanding of utilization management principles and practices.
Develop strategies to manage and prevent disputes and improve Revenue Cycle processes with Revenue Cycle Directors and managers.
Build trusting relationships with hospital leaders to successfully implement new programs.
Build collaborative partnerships and lead cross functional teams to execute on plans and proposals.
Identify process inefficiencies via root cause analysis and design work flow to address opportunities identified.
Develop and implement action plans managing follow-up to achieve outcomes.
Implement targeted process changes including ongoing metric monitoring and management to achieve goals and drive improvement.
Adheres to established departmental policies, procedures, and objectives.
Enhances professional growth and development by accessing educational programs, job related literature, in-service meetings, and workshops/seminars.
Maintains established department/hospital/system policies and procedures, directives, safety, environmental and infection control standards appropriate to this position.
Demonstrates a courteous and professional manner through interactions with internal and external customers.
Integrates scientific principles and research based knowledge in decision making.
Exemplifies a professional image in appearance, manner and presentation.
Engages in self-performance appraisal, identifying areas of strength as well as areas for professional development.
Researches, selects and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes.
Performs other related duties as assigned.