Under broad direction from the Sr. Director of Utilization Management, is responsible for the daily operations of the Centralized Utilization Management Programs for FMOLHS which serves infant, pediatric, adolescent, young adult, adult and geriatric patients. This position collaborates with department heads to comply with organizational standards. They are responsible for planning, developing, implementing and monitoring these system-wide programs. They are also responsible for ensuring cost effective and quality patient care by appropriate utilization of hospital resources while collaborating with facility-based care coordination team to secure appropriate post-acute placement. The Manager performs highly responsible professional nursing and administrative work in accordance with established standards, criteria, procedures, rules, regulations and policies of the organization.
Team
a. Develops and implements the organizations Utilization Management Plan in accordance with the mission and strategic goals of the organization, federal and state law and regulations and accreditation standards.
b. Develops and implements systems, policies and procedures for prospective, concurrent and retrospective case review and reporting quality issues during the utilization review process.
c. Collaborates with physician leaders and market stakeholders when trends are identified related to concurrent administrative or medical necessity denials.
d. Collaborates with market staff and physicians to optimize efficiency of services provided and minimize consumption of resources.
g. Collaborates with facility-based physicians, Physician Advisors, and/or FMOLHS medical directors to operationalize the Centralized Peer-to-Peer Program to defend the admission status and any post-acute placement requirements.
i. Serves as a liaison between hospital providers, family, patient, and physician by working to resolve issues in an efficient manner while keeping the patient's best interests in mind.
j. Communicates with market-based Case Management and physicians to efficiently address barriers to discharge and length of stay outliers.
i. Collaborates with Centralized Denials Management Department to coordinated appeal efforts to secure claim reimbursed on services provided.
j. Acts as an information and referral source by developing relationships with community agencies and services to meet patient needs and ensure that treatment is immediately relevant to the problems the patient is experiencing.
Partnership and Collaboration
a. Provides clinical support, education and operational support as necessary.
b. Provides mentoring and coaching to direct reports to build and strengthen Utilization Management effectiveness.
c. Ensures regular departmental staff meetings are conducted, and action items and follow-up issues are completed.
d. Partners with other Departments to monitor system-wide performance improvement initiatives for Utilization Management measures.
e. Collaborates with the Sr. Director of Utilization Management to analyze and maintain key performance indicators which could impact staffing levels, quality of services, revenues, or expenses.
Quality
a. Actively monitors daily activity to ensure that appropriate priority is given to provide high quality care by ensuring guidelines are followed for core measures through concurrent chart review and follow-up with appropriate healthcare provider.
b. Always maintains highest level of confidentiality with dealing with patients, staff or physician issues.
c. Collects analyzes and maintains data on the utilization of medical services and resources.
d. Monitor department metrics to validate the utilization reviews are provided timely and based on nationally recognized best practice standard to secure certification for billing, including private insurance certifications.
e. Communicates as needed with the utilization management physician advisors and/or medical directors on problematic cases and documents his decisions.
f. Tracks avoidable days and denials. Communicates trends to key stakeholders when identified and facilities operationally feasible action plans to address reimbursement barriers.
g. Collaborates with facility-based physicians, Physician Advisors, and/or FMOLHS medical directors to address denial trends related to documentation deficiencies to support the admission status.
h. Fosters an organizational climate that supports and promotes effective performance improvement efforts.
i. Promptly notifies Sr. Director or Market Stakeholders of possible quality issues.
j. Ensures team conforms to regulatory and organizational requirements.
Other Duties as assigned
a. Ensure departmental operations, including Standard Operating Procedures, staffing, technology use, and competencies, meet regulatory standards and quality objectives.
b. When requested, adjusts personal schedule to meet department/unit needs.
c. Maintains a professional appearance, according to job requirements, always participating in committees or counsels as needed
5 years general or specialty nursing practice and 1 years of management or supervisor experience..
Bachelor's Degree required, BSN or like degree
Registered Nurse (Active Louisiana, Mississippi, multistate/compact or APRN) required.