Nurse Manager Utilization ManagementMedStar Southern Maryland Hospital Center • Washington, DC, United States
Nurse Manager Utilization Management
MedStar Southern Maryland Hospital Center • Washington, DC, United States
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job_description.job_card.job_descriptionContributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations. Actively leads the process of validating medical necessity by utilizing pre-approved criteria and guidelines for continued stay and appropriateness of treatment and discharge planning. Acts as a liaison between IS and the clinical team to identify workflow / system issues and resolutions. Uses technology to enhance decision making and effectiveness. Analyzes the UM monthly reports on LOS, Days per 1000, readmissions, physician denials, denial rates at acute facilities, productivity and other reports as required by MFC Clinical Operations. Reports trends / findings to the Director on at least a monthly basis. Assists staffs with setting personal and educational goals and objectives to enhance their professional development. Develops and implements education programs to coordinate staff development and training needs both for software and clinical training issues. Assists with hiring, training, orientation and assignments of department staff. Assists with the development and evaluation of performance standards. Initiates or makes recommendations for personnel actions. Maintains regular ongoing communication with subordinates to review progress, provide feedback, discuss new developments, and exchange information. Collaborates with the Director and contributes to the achievement of department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Direct management of the Utilization Management Team to assure and maintain high quality and productivity standards; ensure results-oriented utilization management, timely customer service follow-up and strong communication skills. Demonstrates behavior consistent with MedStar Health mission, vision, goals, objectives and patient care philosophy. Demonstrates skill and flexibility in providing coverage for staff and other department managers. Educates and monitors staff regarding timely and accurate documentation in the clinical software system per Clinical Operations policies. Ensures compliance with governmental and accreditation regulations. Leads staff meetings, weekly census, work groups, etc., as assigned. Addresses issues impacting MFC with community agencies and providers. Delivers updated information back to department staff. Maintains current knowledge and functions as a resource to the clinical team regarding benefits, authorizations, enrollment issues, practice guidelines and alternative treatment options in order to accurately coordinate enrollees / provider services. Manages ACD telephone coverage and processes related to PCP and provider questions, eligibility and benefits, transportation, and authorization issues. Monitors and ensures compliance with UM standards, as per MFC policies and procedures. Performs other duties as assigned. Provides backup support in the absence of the Director as required. Works in partnership with the Manager of Case Management and other Managers as appropriate in development of the annual Clinical Operations Plan and the Clinical Operations Appraisal. Provides continuing individual coaching and support to staff and acts as a resource for clinical, social, utilization and appeal review issues as they relate to the Clinical Operations department. Serves as a first line intermediary in inter-associate disagreements; knowing when to escalate issues to the next level of management. Bachelor's degree from an accredited school of nursing or equivalent combination of education and experience required or 3-4 years Utilization management experience required and 5-7 years Diverse clinical experience required and 1-2 years 2 years Supervisory experience required RN - Registered Nurse - State Licensure and / or Compact State Licensure Valid RN License in the State of Maryland, Maryland CCM (Certified Case Manager) required or CCM - Certified Case Manager Valid RN License in the State of Maryland, Maryland CCM (Certified Case Manager) required achievement within 2 years of assuming the Manager position. required Excellent verbal and written communication skills. Ability to follow verbal and written instructions. Proficient computer with Microsoft Office applications especially Word, Excel and PowerPoint. Ability to enter and retrieve information using a PC. Working knowledge of various computer software applications. Knowledge of current trends in health care delivery and population management. Knowledge of NCQA, HEDIS, InterQual and local regulatory guidelines preferred.
General Summary of Position
Responsible for evaluating the necessity, appropriateness and efficiency of the use of medical services procedures and facilities. Responsible for clinical review of all acute services for appropriateness based on medical criteria, the management of healthcare resources necessary and appropriate for achievement of desired outcomes, and the coordination of alternative levels of care for enrollees / members. Works collaboratively with interdisciplinary staff, both internal and external to the organization to facilitate the continuum of care, through education and advocacy to enhance health outcomes.We recruit, retain, and advance associates with diverse backgrounds, skills, and talents equitably at all levels.
- 4 days per week on-site in DC
Primary Duties and Responsibilities
Minimum Qualifications
Education
Experience
Licenses and Certifications
Knowledge, Skills, and Abilities
This position has a hiring range of $100,588 - $180,419
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