Utilization Manager - Registered Nurse - AG

JOB SUMMARY: Performs technical and administrative work required to evaluate the necessity, appropriateness and efficiency of the use of medical services procedures and facilities. Licensed RN responsible for clinical review of all acute and subacute services for appropriateness based on medical criteria. This individual is responsible for the management of healthcare resources necessary and appropriate for achievement of desired acute and subacute outcomes and the coordination of alternative levels of care for membership.


PRIMARY RESPONSIBILITIES:

1. Performs on-site and/or telephonic review of acute and subacute services.
2. Predicts and plans for patient’s needs from pre-admission, through acute and subacute care and post-discharge, in collaboration with the member.
3. Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning.
4. Acts in conjunction with the appropriate manager(s) on a daily basis to assess the inpatient census for appropriate alternative health care service needs.
5. Coordinates with appropriate discharge planning team members, facility utilization management department, physicians and members to coordinate timely discharges.
6. Strives to maintain quality care while effectively utilizing resources.
7. Identifies and reports any quality or utilization issues to the Medical Director.
8. Acts in conjunction with the clinical team related to discharge planning e.g., home care, hospice care, rehabilitation care, special program care, transitional care, occupational therapy, speech, respiratory and physical therapy, durable equipment and disposable supplies.
9. Documents all activities in the appropriate system(s) on a timely basis.
10. Participates in rounds with the Medical Director.
11. Review Plan appeal items for concurrent and retrospective reviews as required and requested.
12. Monitors and facilities appropriate utilization of resources utilizing clinical criteria.
13. Tracks and reports trends of inappropriate utilization of resources to the Medical Director.
14. Participates in a multi-disciplinary clinical team to achieve positive member outcomes.
15. Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.
16. Utilizes effective communication, conflict management and negotiation skills.
17. Utilizes excellent customer service principles to assist internal and external customers.
18. Participates in Quality Improvement Process.
19. Maintains member confidentiality.
20. Other duties as requested or assigned.EDUCATION AND EXPERIENCE:
• Currently licensed RN with three years experience in health care, case management, discharge planning, utilization management, or behavioral health.
• Two years of Utilization Management or Hospital/Acute care experience required.
• Experience working on the community level and with community agencies preferred.

Certification and Licensure:
• Current State RN license
• Certified Professional Utilization Review (as required by Plan)
• Certified Case Managers a plus.
• Must possess a valid driver’s license and access to a motor vehicle.

Principle Accountabilities:
• Computer literate.
• Excellent verbal and written communications skills.
• Strong decision making skills.
• Ability to provide services in an environment that involves multiple health care systems.
• Ability to interact with all relevant components of the health care system.
• Ability to provide services that deal with the individual’s broad spectrum of needs.
• Self-starter with ability to handle multiple projects at one time.
• Appreciation of cultural diversity and sensitivity towards target population.
• Bilingual a plus.

Physical Requirements:
• Must be able to operate a computer.
• Must be able to operate a telephone.
• Must be able to sit for long periods of time.
• Must be able to operate a motor vehicle and travel locally (as required by Plan).