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Job Summary
The Supervisor Utilization Management - Inpatient Clinical Review provides leadership and oversight to the utilization management team, ensuring day-to-day activities align with timelines and quality standards. The key responsibilities for this role involve monitoring utilization review activities and outcomes and staff oversight.
Requirements
EDUCATION
Associates degree in Nursing OR Diploma in Nursing required.
Bachelor's degree in health related field preferred.
LICENSING/CERTIFICATION
Registered Nurse (RN) with current active state license in good standing in the state(s) where job duties are performed required.
EXPERIENCE
Minimum five (5) years' clinical practice experience. OR applicable Masters in related field with minimum three (3) years' experience.
Demonstrated success as an individual contributor in current or related operational/functional area. Exhibits ability to coach and train others; possesses organizational and planning skills. May have team leader experience.
Utilization management experience or background in medical economics preferred.
Surgical or critical care nursing background preferred.
Understanding of the relationship of contractual limitations and evidenced based on standard/non-standard care.
ESSENTIAL SKILLS & ABILITIES
Oral & Written Communication
Ability to make sound judgments and decisions by utilizing evidence based criteria and computer systems, and based on facts and guidelines.
Ability to analyze problems, develop solutions, plan, organize, and control work for maximum efficiency.
Ability to train and educate others on the current pre-certification processes.
Skills
• Active Listening
• Affinite CM
• Affinite UM
• Analytical Decision Making
• Analytical Problem Solving
• Business Compliance
• CCI Edits
• Coaching
• Collaborative Communications
• Compliance 360
• Conflict Resolution Management
• Consultative Approach
• Critical Thinking
• Cross-Functional Communications
• Customer Service Workstation
• Data Analysis
• Documenting/Recording Information
• Educational Development
• Employee Engagement Strategies
• Five9
• Information Interpretation
• Interpersonal Relationship Management
• Management Techniques
• Microsoft Excel
• Microsoft Office
• Microsoft PowerPoint
• Microsoft Word
• Oral Communications
• Problem Sensitivity
• Researching
• Social Awareness
• Support Coordination
• Team Development
• Training and Development
• Written Communication
Responsibilities
• Assists in Insurance Department and legal appeals to answer provider or policy holder concerns.
• Assists in the ongoing development and updating of procedures and guidelines as new ones are identified.
• Assists in the research and development of special projects involving specific providers, contractual issues, medical necessity or medical policy issues, and work flow issues.
• Assists the Legal Division with defense of cases involving review decisions and guidelines, including participating in courtroom activity as needed.
• Conducts review for all inpatient/outpatient hospital, physician, and supplier requests for approval. Attains performance standards as established in the business plan for the division. Participates in quality improvement program.
• Cooperates and works effectively with all regional and departmental staff to facilitate BANA team participants.
• Facilitates appropriate cost effective and cost containment measures.
• Oversees staff to initiate correspondence to physician, suppliers and hospitals requesting additional information on questionable inpatient admissions and out-patient procedures.
• Oversees the day-to-day referral process including telephone calls, faxed clinical, to be reviewed directly by the pre-certification nurse for approval/disapproval. Develops reports to monitor the day-to-day work flow and to ensure Pre-Admit, Post-Discharge, and Nurse Navigators receive referrals timely.
• Oversees work referrals out of queues daily.
• Participates in on-going evaluation of himself/herself and of the Review team. Assists in the development of plans for process improvement.
• Remains current with medical and surgical procedures, products, services and drugs by attending BANA CM Meeting, conferences, home studies, and in-services.
• Remains current with ongoing changes and medical practice through use of evidence based guidelines and medical policy.
• Supervises the hiring, coaching/training, employee development and performance management of assigned team.
• Works collaboratively with and consults with other teams within the Medical Management Area, Customer Service and Claims Processing areas for all product lines, Corporate Medical Director, Staff Attorneys, and others within the Enterprise.
Certifications
Security Requirements
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.
Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.
Employment Type
Regular
ADA Requirements
1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.