General Summary

Under limited supervision, assists the managers of Integrated Care Management in the supervision of the utilization management team. This includes providing guidance in regards to policies and procedures related to concurrent review, denial management, and contract regulations. Provides input regarding human resource functions. Provides input into performance improvement strategies.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by staff assigned to this classification. They are not to be construed as an exhaustive list of all duties.

1. Demonstrates comprehensive understanding and expertise in all aspects of Utilization Management, knowledge of insurance coverage, and regulatory mandates.
2. Acts as a resource and mentor to the Utilization Review staff.
3. In the absence of the Managers, assists in managing the daily departmental operations with the goal of maintaining adequate staffing levels and efficient workflow, including monitoring performance issues.
4. Monitors daily workflow issues and addresses issues related to workflow in collaboration with the Managers/director, as necessary.
5. Contributes to the performance evaluation process by providing feedback to the Managers/Director and assisting the creation of professional development plans for UR Coordinators.
6. Assists with orientation of new Utilization Review Nurses, and collaborate in the planning and monitoring progress in conjunction with other staff, as necessary.
7. Communicates and collaborates routinely with the physician advisor, Care Management Managers/Director, and attending physicians to resolve problems regarding acuity and level of care.
8. Performs concurrent and retrospective reviews to determine medical necessity using accepted criteria based on age specific needs. Interacts with and assists third party payer reviewers to facilitate appropriate care and ensure payment of services.
9. Actively participates in ongoing professional improvement and educational opportunities.
10. Provides input into the hiring/interview process for new case manager and/or utilization management applicants.
11. Helps in collecting, tabulating, and analyzing data in collaboration with the case management team, medical staff, and hospital performance improvement initiatives. Assist in implementing strategies to correct or modify trends seen through data analysis and outcome monitoring.
12. Participates in multidisciplinary quality and service improvement teams.
13. Performs chart reviews to ensure chart compliance metrics achieved.
14. Performs other duties as assigned.