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Job Type:
RegularScheduled Hours:
40Job Summary:
The Manager of Utilization Management develops all UM department policies, protocols and programs. Manages and assures quality payer reviews and submissions while maintaining the philosophy of St. Elizabeth Healthcare. Educates and coaches staff. Acts as a liaison to physician advisors, payers, and medical necessity criteria contractors. Partners with the Finance Department to prevent, communicate, appeal and trend denials. Works with the Director and other managers to oversee the departments daily operations.Demonstrate respect, dignity, kindness and empathy in each encounter with all patients, families, visitors and other employees regardless of cultural background.
Job Description:
- Manage and coach a subordinate group.
- Develop, promote and maintain professional relationships, both internally and externally.
- Train, develop and coach, counsel, assign duties and work schedules. Evaluate job performance and review performance appraisal with personnel. Initiate or recommend necessary counseling, disciplinary actions, termination and commendatory actions.
- Design/implement efficient services, offer revenue enhancements, monitor expenses, benchmark, encourage service excellence and provide effective communications.
- Delegate and check daily assignments. Prioritize and delegate tasks and projects within the department.
- Develop and manage department budget
- Research and prepare budget proposals.
- Monitor department expenditures to meet budget targets.
- Encourage resourceful use of approved funds to execute projects.
- Identify annual and long-term resources needed.
- Manages and assures quality payer reviews and submission while maintaining the philosophy of St. Elizabeth Healthcare.
- Ensures Medicare/Medicaid Compliance and other third party regulations impacting reimbursement affecting the overall organizational financial strength. Understand payment methodologies on all contracted health plans and meet their UM criteria.
- Intervenes with physicians when medical necessity for hospital stay is not present or evident in documentation and acts as a liaison to physician advisors, payer, and medical necessity criteria contractors. Communicates and intervenes regarding payer issues.
- Partners with the Finance Department to prevent, communicate, appeal and trend denials.
- Administrative duties: represent department on SEH and community committees, as assigned; assist the Director in monitoring and improving department productivity; serve as manager in charge in the absence of the Director; maintain open communication with the Director, including participating in any scheduled leadership meetings.
- Human Resource duties: participate in the interviewing, selection and orientation of new hires; participate in addressing employee relations issues, including disciplinary action when needed.
- Performance Improvement duties: assist with the development and compilation of PI data and initiates implementation of the established action plan to assure quality care is provided.
- Performs other duties as assigned.
Education, Credentials, Licenses:
- RN
- Licensed or eligible for licensure in state where work is being performed.
Specialized Knowledge:
Knowledge of RN clinical practice in health care setting.
Good communication, organizational and interpersonal skills.
Utilization of resources, cost per case
Commercial insurance, government payer regulations
Medical necessity criteria
Admission level of care assignment
Mentor, coach and resource to staff
Kind and Length of Experience:
Minimum of five years of RN practice in health care
FLSA Status:
ExemptRight Career. Right Here. If you're looking for the right careers in healthcare, the right place to be is at St. Elizabeth. Join us, and you'll take pride in the level of care we offer our community.
