Utilization Review Manager

This job manages the daily operations of all assigned divisions within the case management department in collaboration with the case management and social services leadership.

Manages plans and organizes all business functions including staffing, staff development, training, purchasing, and budgeting.

Manages initiatives to improve processes, maximize efficiency, satisfy internal and external customers, maintain high employee morale, empower, and serve respective teams.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and / or ability required.

Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties.

This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities.

Contents are subject to change at the company's discretion.

Education :

• Required - Bachelors degree in nursing (BSN).
• Master's degree in social work (MSW).

Work Experience :

• Required - 3 years of case management experience in an acute care setting or similar environment.
• Experience in compliance management systems (CMS) regulations, compliance and quality metrics.
• Experience managing denials and appeals of all payer cases in a timely and organized manner.
• Preferred - 1 year of management level experience.
• Experience in managed care, quality management, regulatory compliance, medical management, or other related MCO departments / functions.

Certifications :

• Required - Current registered nurse (RN) license in state of practice.
• MSW accepted in lieu of registered nurse (RN) licensure.
• Preferred - Certification in Case Management (CCM) or Certified Professional in Healthcare Management (CPHM).

Knowledge Skills and Abilities (KSAs) :

• Proficiency in using computers, software, and web-based applications.
• Effective verbal and written communication skills and ability to present information clearly and professionally to varying levels of individuals throughout the patient care process.
• Conflict resolution skills and ability to demonstrate good judgement in performing duties.
• Knowledge of business management principles including operations, finance, audit, authorizations, referrals, discharge planning, personnel, and resource management.
• Understanding of financial statements and ability to manage within a budget, analyze trends, and make recommendations.
• Must be able to work a flexible work schedule (e.g. 24 / 7, weekend, holiday, on call availability)

Job Duties :

• Leads respective teams with high motivation and responsibility for the welfare of the entire team making decisions based on good judgement rather than popularity.
• Promotes, supports, encourages, and fosters maximum communication across case management with the purpose of making one accessible and available to all team members ensuring that effective problem analysis is exercised across all levels of the organization.
• Conducts personal leadership self-development with the conscious intention to always become a better, more effective leader.
• Manages the implementation controls for all precertification, continued stay, authorization and billing processes as well as policies and procedures required for success under the direction of the case management leadership.
• Leads special and audit projects independently with the end goal of ensuring that the internal control environment is not compromised and the awareness of the process control culture is increasingly heightened.
• Determines appropriate staffing levels and the interviewing, hiring, performance review, and termination of employees within practice unit(s);

maintains employee schedules to assure appropriate coverage.

• Develops departmental specific systems to assure an environment that emphasizes patient courtesy and responsive service delivery.
• Performs other related duties as required.

The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills.

Other duties may be added, or this description amended at any time.

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About Ochsner Health :

Ochsner Health is a system that delivers health to the people of Louisiana, Mississippi and the Gulf South with a mission to Serve, Heal, Lead, Educate and Innovate.

Ochsner Health is a not-for-profit committed to giving back to the communities it serves through preventative screenings, health and wellness resources and partnerships with innovative organizations that share our vision.

Ochsner Health healed more than 876,000 people from across the globe in 2019, providing the latest medical breakthroughs and therapies, including digital medicine for chronic conditions and telehealth specialty services.

Ochsner Health is a national leader, named the top hospital in Louisiana and a top children’s hospital by U.S. News & World Report.

As Louisiana’s leading healthcare educator, Ochsner Health and its partners educate thousands of healthcare professionals annually.

Ochsner Health is innovating healthcare by investing in new technologies and research to make world-class care more accessible, affordable, convenient and effective.

Ochsner's team of more than 26,000 employees and 4,500 providers are working to reinvent the future of health and wellness in the region.

To learn more about Ochsner Health, please visit www.ochsner.org. To transform your health, please visit www.ochsner.org / healthyyou.