Supervisor Utilization Management

FMOLHS•Baton Rouge, LA

About The Position

The Supervisor, Utilization Management is responsible for the supervision of the FMOLHS Utilization Team which serves infant, pediatric, adolescent, young adult, adult and geriatric patients. Is responsible for ensuring compliance with healthcare regulations, and providing supervision, guidance, and support to clinical staff. Implement standard operating procedures based on the nationally recognized best practice standards. Incumbent performs highly responsible professional nursing and administrative work in accordance with established standards, criteria, procedures, rules, regulations and policies of the agency. Collaborate with department heads to comply with these standards.

Requirements

Graduate of an accredited school of nursing program.
5 years' experience case management, utilization, or in a healthcare setting.
Some management experience.
Registered Nurse (Active Louisiana, Mississippi, multistate/compact or APRN) required.

Responsibilities

Collaborates with physician leaders and market stakeholders when trends are identified related to concurrent administrative or medical necessity denials.
Collaborates with market staff and physicians to optimize efficiency of services provided and minimize consumption of resources.
Implements the organizations Utilization Management Plan in accordance with the mission and strategic goals of the organization, federal and state law and regulations and accreditation standards.
Implements systems, policies and procedures for prospective, concurrent and retrospective case review and reporting quality issues during the utilization review process.
Collaborates with facility-based physicians, Physician Advisors, and/or FMOLHS medical directors to defend the admission status and any authorization requirements.
Communicates with market-based Case Management and physicians to efficiently address barriers to discharge and length of stay outliers.
Collaborates with Centralized Denials Management Department to coordinated appeal efforts to secure claim reimbursed on services provided.
Provides clinical support, education and operational support as necessary.
Provides mentoring and coaching to direct reports to build and strengthen Utilization Management effectiveness.
Ensures regular departmental staff meetings are conducted, and action items and follow-up issues are completed.
Partners with other Departments to monitor system-wide performance improvement initiatives for Utilization Management measures.
Collaborates with the Utilization Management Leadership Team to analyze and maintain key performance indicators which could impact staffing levels, quality of services, revenues, or expenses.
Actively monitors daily activity to ensure that appropriate priority is given to provide high quality care by ensuring guidelines are followed for core measures through concurrent chart review and follow-up with appropriate healthcare provider.
Always maintains highest level of confidentiality with dealing with patients, staff or physician issues.
Collects analyzes and maintains data on the utilization of medical services and resources.
Monitor department metrics to validate the utilization reviews are provided timely and based on nationally recognized best practice standard to secure certification for billing, including private insurance certifications.
Communicates as needed with the utilization management physician advisors and/or medical directors on problematic cases and documents his decisions.
Collaborates with facility-based physicians, Physician Advisors, and/or FMOLHS medical directors to address denial trends related to documentation deficiencies to support the admission status.
Fosters an organizational climate that supports and promotes effective performance improvement efforts.
Ensures team conforms to regulatory and organizational requirements.
Ensure departmental operations, including Standard Operating Procedures, staffing, technology use, and competencies, meet regulatory standards and quality objectives.