Perform duties to conduct and manage the day to day operations of the utilization management function. Communicate with staff to facilitate daily department functions.
• Review analyses of activities, costs, operations and forecast data to determine progress toward stated goals and objectives.
• Promote compliance with federal and state regulations and contractual agreements.
• Develop, implement and maintain compliance, policies and procedures regarding medical utilization management functions.
• Develop, implement, and maintain utilization management programs to facilitate the use of appropriate medical resources and decrease the business unit's financial exposure.
• Compile and review multiple reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management.
• Facilitate on-going communication between utilization management staff and contracted providers.
• Develop staff skills and competencies through training and experience. Available to non-clinical staff as a resource for clinical questions.
Education/Experience: Bachelor’s degree in related field or equivalent experience. Bachelor’s degree in nursing preferred. 3+ years utilization management and recent nursing experience in an acute care setting particularly in medical/surgical, pediatrics, or obstetrics and management experience. Thorough knowledge of utilization management and clinical nursing. Familiarity with Medicare and Medicaid managed care practices and policies, CHIP and SCHIP. Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.
License/Certification: RN license. Case Management Certification preferred.