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Job Summary:
Responsible for providing leadership and managing all processes/services within Utilization Management program; assumes responsibility for implementing standards of practice, evidenced based medical guidelines, departmental policies and procedures, and maintaining and guiding the quality of patient care delivered; assures staff and program compliance with CMS and other payer regulatory compliance and Utilization Review standards, practices and procedures policies/procedures Responsible for financial performance, human resource management and staff engagement, appropriate reporting, and coordinating program functions with physicians and other hospital departments to assure that optimal program quality outcomes and patient throughput are achieved. Creates an environment which enables the system to fulfill its mission and goals, fosters communication and collaborative practice with physicians and other departments. Participates and supports the UM Committees within the hospital and or other hospital committees to ensure program requirements are met. Core Responsibilities and Essential Functions:
Customer/Employee Satisfaction:- Promotes a positive environment to patients, families, staff and the community.
- Responds to inquiries and complaints effectively and in a timely manner and promotes a positive, professional image serving as a liaison between staff, physicians, and administration.
- Demonstrates commitment to teamwork through positive interactions and feedback to/from subordinates, physicians, peers and other customers.
- Accepts responsibility for employee morale and team performance toward goal achievement. Develops measurable, team goals, monitors progress and keeps staff abreast of progress toward achievement.
- Utilizes department metrics and develops plans to direct departmental practice performance initiatives, staff satisfaction initiatives and improvements in physician relations and overall customer service.
- Represents WellStar by exhibiting values and credo. Coordinates Patient Care
- Continually assesses current trends/clinical/technological advances in best practice and takes appropriate action to improve outcomes and cost-effective care.
- Reviews and updates department/program specific standards/policies/procedures as needed to assure compliance with established standards, standardization efforts and current practice.
- Oversees the daily operation of the program and, in collaboration with physicians and senior leadership.
- Assesses, provides for the delivery of and evaluates quality of services delivered within the program.
- Insures that all staff collaborates with Discharge Planners to enable the system to deliver services more cost effectively in the most appropriate setting to meet patient needs and communicates these needs with payers.
- Serves as an expert for payer requirements and communications to hospital staff/personnel and other health care professionals within the organization and community.
- Demonstrates, via role modeling and consultation, advanced knowledge and practice in the assessment, diagnosis, treatment and evaluation of human responses to actual and/or potential health problems.
Consults with healthcare providers, ancillary services, patients and significant others to assess and identify individual patient care needs. Education/Outcomes Management * Develop, revise and maintain education materials. * Communication with MD offices in admission process and obtaining authorizations
Clinical resource for staff development.
Resource for Utilization Review within continuum of care.
Sustain professional competency; pursue clinical skill development and specialty certification.
Facilitate case management across the pathway to assure seamless integration of care.
Develop an outcome scorecard to be utilized for benchmarking program.
Identify PI opportunities to achieve compliance with best practice * Track, trend and analyze data. * Define opportunities for improvement from data analysis. Utilization Review
Assumes responsibility for ongoing program coordination across the continuum from admission through discharge along with all associated follow-up.
Maintains competency in criteria review guidelines. Insures Utilization Review competencies are completed annually.
Analyzes, interprets and makes recommendations based on Utilization Review Reports, productivity data and financial measures.
Serves as a liaison between clinical departments by analyzing individual dept. performance about established goals.
Ensures compliance with CMS/commercial payor standards to maintain contract compliance and participates in JOC Meetings. Fiscal Accountability
Assists with the development and implementation of operational and capital budgets that are consistent with system-wide, facility/divisional goals and objectives.
Assists with the establishment of productivity measures and facilitates program and team achievement of established goals.
Maintains FTE, salary and expense budgets at or below budgeted levels, demonstrating the ability to review/analyze current/historical data relevant to budget variances.
Assists with the development of collaborative approaches that promote quality, cost-effective utilization services across the continuum. Liaison for Regulatory Compliance
Coordinates with leadership on compliance and regulatory standards as well as contractual guidelines.
Develops/implements professional standards for the program based upon recognized standards of care, Joint Commission and CMS standards, state/federal regulations and overall system policies and procedures.monitors staff compliance of regulatory standards.
Serves on hospital and system committees as needed.
Participates in identifying learning needs for Utilization Review Team, assures staff competencies on an annual basis.
Makes staff aware of community outreach and educational opportunities.
Represents team at local, State, and national meetings through educational offerings and through involvement in professional organizations.
Demonstrates motivation for learning through independent reading, professional networking and communicates professional expertise through publications and presentations at the local, regional, and national level. Performs other duties as assigned Complies with all WellStar Health System policies, standards of work, and code of conduct.
Required Minimum Education:
Bachelors Nursing or Diploma (Nurse) Nursing or Masters Nursing-Preferred
Required Minimum License(s) and Certification(s):All certifications are required upon hire unless otherwise stated.
RN: Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact
Additional License(s) and Certification(s):Required Minimum Experience: Will consider years of experience in case management in lieu of Masters degree Required and Minimum 3 years experience in the management of a multidisciplinary staff in the field of case management Required and Minimum 3 years experience in a hospital environment required Required Required Minimum Skills: Strong communication and interpersonal skills required. Ability to multitask
