Supervisor Utilization Management Inpatient Clinical Review

Arkansas Blue Cross•Little Rock, AR

9d•Onsite

About The Position

The Supervisor Utilization Management - Inpatient Clinical Review provides leadership and oversight to the utilization management team, ensuring day-to-day activities align with timelines and quality standards. The key responsibilities for this role involve monitoring utilization review activities and outcomes and staff oversight.

Requirements

Associates degree in Nursing OR Diploma in Nursing required.
Registered Nurse (RN) with current active state license in good standing in the state(s) where job duties are performed required.
Minimum five (5) years' clinical practice experience.
OR applicable Masters in related field with minimum three (3) years' experience.
Demonstrated success as an individual contributor in current or related operational/functional area.
Exhibits ability to coach and train others; possesses organizational and planning skills.
May have team leader experience.
Oral & Written Communication
Ability to make sound judgments and decisions by utilizing evidence based criteria and computer systems, and based on facts and guidelines.
Ability to analyze problems, develop solutions, plan, organize, and control work for maximum efficiency.
Ability to train and educate others on the current pre-certification processes.
Active Listening
Affinite CM
Affinite UM
Analytical Decision Making
Analytical Problem Solving
Business Compliance
CCI Edits
Coaching
Collaborative Communications
Compliance 360
Conflict Resolution Management
Consultative Approach
Critical Thinking
Cross-Functional Communications
Customer Service Workstation
Data Analysis
Documenting/Recording Information
Educational Development
Employee Engagement Strategies
Five9
Information Interpretation
Interpersonal Relationship Management
Management Techniques
Microsoft Excel
Microsoft Office
Microsoft PowerPoint
Microsoft Word
Oral Communications
Problem Sensitivity
Researching
Social Awareness
Support Coordination
Team Development
Training and Development
Written Communication

Nice To Haves

Bachelor's degree in health related field preferred.
Utilization management experience or background in medical economics preferred.
Surgical or critical care nursing background preferred.
Understanding of the relationship of contractual limitations and evidenced based on standard/non-standard care.

Responsibilities

Assists in Insurance Department and legal appeals to answer provider or policy holder concerns.
Assists in the ongoing development and updating of procedures and guidelines as new ones are identified.
Assists in the research and development of special projects involving specific providers, contractual issues, medical necessity or medical policy issues, and work flow issues.
Assists the Legal Division with defense of cases involving review decisions and guidelines, including participating in courtroom activity as needed.
Conducts review for all inpatient/outpatient hospital, physician, and supplier requests for approval. Attains performance standards as established in the business plan for the division. Participates in quality improvement program.
Cooperates and works effectively with all regional and departmental staff to facilitate BANA team participants.
Facilitates appropriate cost effective and cost containment measures.
Oversees staff to initiate correspondence to physician, suppliers and hospitals requesting additional information on questionable inpatient admissions and out-patient procedures.
Oversees the day-to-day referral process including telephone calls, faxed clinical, to be reviewed directly by the pre-certification nurse for approval/disapproval. Develops reports to monitor the day-to-day work flow and to ensure Pre-Admit, Post-Discharge, and Nurse Navigators receive referrals timely.
Oversees work referrals out of queues daily.
Participates in on-going evaluation of himself/herself and of the Review team. Assists in the development of plans for process improvement.
Remains current with medical and surgical procedures, products, services and drugs by attending BANA CM Meeting, conferences, home studies, and in-services.
Remains current with ongoing changes and medical practice through use of evidence based guidelines and medical policy.
Supervises the hiring, coaching/training, employee development and performance management of assigned team.
Works collaboratively with and consults with other teams within the Medical Management Area, Customer Service and Claims Processing areas for all product lines, Corporate Medical Director, Staff Attorneys, and others within the Enterprise.