Utilization Management Manager

LCMC Health•New Orleans, LA

About The Position

The RN Manager of Care Management is responsible for day-to-day administration of the Care Management Department, ensuring quality care, consistency, and ongoing departmental improvement. The role manages daily utilization review and case management tasks and coordinates the responsibilities of direct reports. It also participates in implementing and coordinating approved processes to identify problems and opportunities for improvement and to support resolutions that maximize the quality of care provided to patients. The manager assists with supervision and staff development, departmental policies and procedures, regulatory compliance, case management coordination, utilization review, claims resolution, denials and appeals, and responses to cases referred by other departments. The role represents the department on hospital and medical staff committees as assigned and serves as a primary contact for staff in concerned and revenue cycle departments.

Requirements

Three years of case management/management experience required.
Registered Nursing License (RN) from the Louisiana State Board of Nursing required.

Nice To Haves

Supervisory experience preferred.
Certified Case Manager certification preferred.

Responsibilities

Assume responsibility for day-to-day administration of the Care Management Department to support quality care, consistency, and continuous improvement.
Assist in supervising staff responsible for care management.
Assist with employee orientation and performance appraisals.
Assist in reviewing and revising departmental policies and procedures.
Monitor departmental compliance with HIPAA.
Represent the department at hospital and medical staff committees as assigned.
Work and collaborate with other departments to resolve outstanding claims.
Monitor the utilization review process to ensure program effectiveness.
Assign reviews to case managers.
Assist with denials and appeals.
Monitor and maintain the department calendar and vacation/time-off requests.
Monitor case management work queues.
Assist in facilitating compliance with regulatory standards, including TJC and CMS.
Keep abreast of regulatory agency standards and help ensure hospital compliance with current case management regulations.
Serve as the entry point for cases referred by any department, work queues, and other referral venues.
Conduct research and respond to all referred cases.
Participate in implementing and coordinating approved mechanisms to identify problems and opportunities for improvement and foster resolutions that maximize quality of care.