UTILIZATION MANAGER

Southwest General Health Center•Middleburg Heights, OH

28d

About The Position

The Utilization Manager is responsible for carrying out admission and concurrent stay screening reviews of the assigned patient population during the episode of care under defined guidelines for acute care case management to ensure the appropriateness of services, utilization of hospital resources and quality of care rendered. Accurate and efficient application of screening criteria will be applied to identify and support patients being placed in the appropriate hospital level of care via emergency, scheduled or direct admission processes. Combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Through continuous assessments, problem identification and education, the Utilization Manager facilitates the quality of health care delivery in the most cost effective manner. The Utilization Manager must be able to demonstrate the knowledge and skills necessary to provide services appropriate to age groups according to specific chronological age, developmental age, and/or psycho-social maturity. The Utilization Manager will work collaboratively with management, staff, and departments involved in the patient's plan of care. The Utilization Manager's responsibility is to collect data and clinical review summaries on patients concurrently for both utilization review and quality assessment. The utilization data and clinical summaries are shared with insurance companies to obtain certification of days and prevent denial of payment for services. Utilization Managers will communicate with physician's, hospital staff, outside agencies such as insurance companies, and patients regarding assigned level of care and associated resource utilization.

Requirements

Graduate of an accredited school of nursing and current licensure by Ohio State Board of Nursing.
Minimum of five (5) years recent experience in clinical nursing or related nursing field. (e.g. Case Management or Utilization Review).
Excellent critical thinking, communication, and computer skills are essential to success in this role.
Current Registered Nurse license by the Ohio State Board of Nursing required.

Nice To Haves

Bachelors (BSN) preferred.
Previous Care Management, Case Management or Care Coordination experience preferred.
ACM or CCM certification preferred.

Responsibilities

Carrying out admission and concurrent stay screening reviews
Ensure the appropriateness of services, utilization of hospital resources and quality of care rendered
Identify and support patients being placed in the appropriate hospital level of care
Reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided
Facilitates the quality of health care delivery in the most cost effective manner
Collect data and clinical review summaries on patients concurrently for both utilization review and quality assessment
Communicate with physician's, hospital staff, outside agencies such as insurance companies, and patients regarding assigned level of care and associated resource utilization.