Utilization Management Manager-Utilization Mgmt- Days

Memorial Hospital at Gulfport•Gulfport, MS

16d

About The Position

Oversee the management of patient care utilization, ensuring appropriate healthcare services are provided while optimizing resource use. This individual will be responsible for leading a team of nurses who review medical necessity, appropriateness and efficiency of healthcare services. Ensure compliance with regulatory requirements and maintain high standards of care.

Requirements

Bachelor Degree Bachelor of Science in Nursing, with an active unrestricted license
License Nursing degree (RN, BS, BSN, or advanced degree) and unrestricted active nursing license
5 years Nursing experience with at least 2 years in Utilization Management or case management role
In depth knowledge of healthcare utilization management processes, medical terminology and clinical guidelines
Familiarity with payer requirements and regulation including Medicare, Medicaid and private insurers
Working knowledge of applications that are used to enhance utilization management based on evidenced based approach and guidelines
Strong knowledge of Microsoft Office applications
Analytical Skills: The ability to analyze large data sets, determine trends, synthesize results, and deliver prioritized details through effective reporting
Communication Skills: Strong communication and interpersonal skills for effective collaboration and education
Problem-Solving Skills: The capacity to understand issues, derive many potential solutions, troubleshoot discrepancies, and understand systematic approaches to problem resolution
Attention to Detail: Precision is essential when reporting critical analysis to inform decision-making and operational change
Time Management: Managing multiple tasks and deadlines while prioritizing work is essential in a fast-paced healthcare environment
Technology Proficiency: Beyond EHR systems, familiarity with various billing software and technology tools

Nice To Haves

Master's Degree Nursing or other clinical discipline, Health Administration, Finance, Business Administration, or a related field
2 years Leadership or management experience in nursing or related field

Responsibilities

Supervise and lead the UM nursing team and Pre-Certification Specialists, ensuring the review of patient cases for appropriate medical necessity and care protocols
Develop, implement and maintain UM policies and procedures in accordance with healthcare regulation and organizational standards
Conduct regular training and provide ongoing support for UR team to improve knowledge and performance
Collaborate with physicians, other healthcare providers and insurance companies to review and improve treatment plans.
Ensure all services are medically necessary and cost effective
Evaluate and analyze healthcare utilization trends, identify opportunities for improvement and solutions to improve outcome
Monitor and ensure compliance with regulatory requirements including Medicare, Medicaid and other payer policies
Prepare and present reports on utilization metrics, case reviews and outcomes to administration leadership groups
Resolve complex case issues and provide guidance on challenging utilization decisions
Ensure accurate documentation of all UM reviews, ensuring compliance with internal and external audit
Foster effective communication between departments, stakeholders and healthcare professionals