RN Manager, Regional Utilization Management - Inpatient - Aurora, CO - Manager
Company: The Medical Center of Aurora
Location: Aurora
Posted on: May 21, 2023
Job Description:
RN Manager, Regional Utilization Management - Inpatient -
Aurora, CO--Salary Range: --$54.71/hour - $64.33/hour--Manages the
day to day utilization management function of a team or teams of
clinicians ensuring the accurate and timely prior authorization of
designated healthcare services, including concurrent and
retrospective review of authorization requests, including discharge
planning activities when needed (collective referred to as
"Utilization Review") for the Colorado region. Manages utilization
review staff working collaboratively with UM physicians and
clinical appeals team, supervises the activities of the unit staff,
prepares department for internal and external audits, conducts
utilization management audits and ensures compliance with policies
and procedures for adherence to governmental and accredited agency
standards. Manager provides assistance and feedback to UR staff on
a monthly basis.Essential Responsibilities:
- Manages the clinical team and or teams that complete medical
necessity reviews for authorization and concurrent requests.
- Responsible for the planning and decision-making related to
utilization review.
- Develops and implements departmental policies and procedures.
Develops, implements, and maintains utilization management programs
to facilitate the use of appropriate medical resources by health
plan members/patients.
- Manages monitoring of staff workload, reviews productivity, and
conducts quality reviews.
- Maintains daily oversight of authorization review work queues,
and assignments with staff daily to insure appropriate
coverage.
- Identifies and monitors services with potential for undesirable
variation to ensure accurate and consistent application of benefit
and clinical criteria.
- Develops and reviews medical necessity criteria and utilization
management practices including a formal process of monitoring and
evaluating the necessity, appropriateness, efficiency,
effectiveness, and safety of medical services to achieve favorable
healthcare outcomes.
- Work in partnership with the Utilization Management Physicians
on affordability and cost initiatives to reduce inappropriate and
or over utilization of medical and or behavior health
services.
- Ensures compliance with national and state
regulatory/accreditation requirements related to utilization
management by partnering with other departments and facilitating
workgroups in maintaining survey readiness to ensure that all
annual requirements are met. Engages in
monthly/quarterly/annual/triennial internal and external
utilization management audits and surveys and delegation oversight
audits, as necessary.
- Manages and oversees the utilization review management training
and education program for Utilization Review staff across the
region. Ensures post-course evaluation tools and other materials
are developed. Manages training and education schedules. Ensures
performance measures are developed and staff is managed to such
measures consistently and appropriately. Serves as Subject Matter
Expert (SME) for Utilization Review workflow issues, complex cases,
denials, and internal/external customers.
- Manages including hiring, training, performance evaluations and
terminations.
- Facilitates on-going communication among Utilization Review
staff, internal providers, and external/contracted
providers.--#RNMGR
--Basic Qualifications:--Experience
- Minimum three (3) years of clinical and medical
utilization/review management experience. --Education
- Associate degree in Nursing with current unrestricted license
and/or, Masters degree in social work.
- High School Diploma or General Education Development (GED)
required. --License, Certification, Registration
- Registered Nurse License (Colorado) OR Licensed Social Worker
(Colorado) --Additional Requirements:
- Thorough knowledge of utilization management and clinical
practice.
- Familiarity with Medicare and Medicaid managed care practices
and policies, CHIP and SCHIP.
- Knowledge of regulatory/accreditation requirements (NCQA, DMHC,
DHCS, CMS, Medi-Cal Plan Partners, Special Needs Plan (SNP)).
--Preferred Qualifications:
- Recent clinical experience in a hospital, LTACH, AIR or SNF
setting preferred.
- Bachelors degree in nursing preferred.
- Case Management Certification preferred.
Keywords: The Medical Center of Aurora, Aurora , RN Manager, Regional Utilization Management - Inpatient - Aurora, CO - Manager, Executive , Aurora, Colorado
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