Mgr Nurse Utilization

SUMMARY:

Under the direction of the Director of Professional Staff Services, the Utilization Manager acts as a liaison to hospital leadership, Case Management, Compliance, Revenue Cycle Departments, and Finance, and serves as an expert in utilization management. This position is part of an interdisciplinary team consisting of the Director of Professional Staff Services and Utilization Management Physician Advisors that review and determines the appropriateness of hospital admissions and medical necessity for continued stay, as well as assuring medical documentation accurately reflects the care that is or was being provided to the patient in collaboration with bed control, case management, coding, and billing. The Utilization Nurse Manager is responsible for monitoring listservs and websites related to Medicare and State regulations for any new and upcoming criteria related to the hospital as well as gathering, developing, and disseminating information to provide regulatory analysis of documentation gaps driving denial trends. As needed, this position may also develop, implement, and assign action plans.

ESSENTIAL FUNCTIONS:

Participates in personal professional growth and development through publications, seminars, workshops, conferences, and professional affiliates.

Acts as an education resource to the clinicians and organizational leadership with regards to local, state and federal utilization issues. Prepares or assists with creating accurate presentation materials including but not limited to agenda, minutes, reporting, and process improvement as needed.

Maintains strong working knowledge of clinical practice, changes in technology, and regulatory issues.

Responsible for collaborating on applicable audits, any deliverables to plans and regulatory agencies, in conjunction with compliance department and billing office including the implementation of applicable corrective action plans and staff training.

Creates and analyzes reports to identify and/or validate concerns related to utilization management using Epic, SAP BusinessObjects (BI Launchpad/Infoview), Care Discovery, Sharepoint, and any other applications as necessary.

Maintains accurate records, databases, tracking of accounts, correspondence, actions and outcomes.

Implements new processes as needed in response to process improvement, corrective action and follow up based on identified trends and needs for the managed care population.

Responsible for assisting with concurrent reviews, retrospective reviews including UM Workqueue, chart review, denials management, utilization monitoring, and all other utilization management requirements set forth by plans or regulatory agencies.

Creates and maintains current policies, procedures, work plans, and program descriptions for all applicable regulatory agencies.

Performs related duties as applicable.

MINIMUM QUALIFICATIONS

EDUCATION:  Bachelor’s degree from a qualified, nationally-accredited nursing program, or an equivalent combination of relevant education and experience. Master’s degree preferred.

EXPERIENCE:  Three (3) years RN nursing experience, preferably in an acute care setting. 

LICENSURE OR CERTIFICATION:  Active unrestricted RN license within the State of Arizona, or NLC.  Epic certification preferred.

KNOWLEDGE, SKILLS AND ABILITIES: 

• Demonstrated Project Management skills
• EPIC reporting proficiency as well a competency navigating the EHR
• Skill in meeting facilitation as well as large and small group presentations.
• Skill in both written and oral communications with internal and external professions of varying degrees and licenses.
• Skill in the use of computer applications, and statistical analysis using a variety of tools such as EXCEL, Access, Sharepoint, and MSOffice, etc.
• Ability to maintain high quality work while meeting strict deadlines