Position title
Utilization Management Manager
Description
This role is responsible for managing care management activities, ensuring compliance with federal and state healthcare regulations, and maintaining high-quality service delivery. The UM Manager collaborates with other healthcare departments to enhance the effectiveness of utilization management and improve patient outcomes.
Responsibilities
- Directly manage and mentor a team in the UM department.
- Ensure efficient day-to-day operations and support the team in meeting organizational goals.
- Foster a positive work environment that encourages teamwork, professional development, and staff retention.
- Conduct regular performance evaluations and provide coaching to improve individual and team performance.
- Oversee and ensure adherence to the organization’s utilization management policies, guidelines, and workflows.
- Collaborate with physicians, case managers, and other healthcare professionals to ensure that patients receive medically necessary services efficiently.
- Ensure compliance with Medicare, Medicaid, and other applicable regulations related to utilization management.
- Monitor and improve processes to optimize resource utilization, manage costs, and enhance patient outcomes.
- Analyze utilization data to identify trends, areas for improvement, and opportunities for cost reduction.
- Lead and support process improvement initiatives, including project management efforts aimed at increasing the effectiveness and efficiency of the UM department.
- Utilize data to drive decision-making and develop strategies that improve patient care and financial outcomes.
- Ensure all UM activities comply with applicable federal and state regulations, including Medicare and Medicaid rules.
- Develop, implement, and update policies related to UM and ensure staff adherence.
- Remain up-to-date on changes in healthcare laws and regulations, integrating new requirements into the UM processes.
- Act as a liaison between the UM department and other teams.
- Maintain effective communication with healthcare providers, patients, and their families regarding care plans and utilization processes.
- Provide data and reports to senior management on UM activities, trends, and outcomes.
- Oversee the use of computer applications for electronic documentation, ensuring proper use of systems like MS Office, EPIC, and Clinical Care Advanced.
- Ensure accurate and timely documentation of all UM activities in line with organizational standards and regulatory requirements.
- Be open to accepting new challenges and tasks as they arise.
Qualifications
- Excellent communication and interpersonal skills.
- With an active unencumbered Registered Nurse (RN) license in Oregon.
- Bachelor of Science in Nursing (BSN) preferred.
- Master’s degree in a related field is preferred.
- Minimum of five (5) years of care management experience, with at least three (3) years in a leadership or management role.
- Experience in data analytics, project management, and process design is required.
- Strong understanding of health care delivery systems, managed care patients, and utilization management.
- Expertise in the use of computer applications such as MS Office, EPIC, and Clinical Care Advanced for electronic documentation.
- In-depth understanding of Medicare and Medicaid rules and regulations.
- Familiarity with health plan benefit structures and policy guidelines.
- Case Management Certification (CCM) or Utilization Management Certification (MCG) is preferred but not required.
- Attention to detail in managing compliance with regulations and ensuring accurate documentation.
- Ability to work under pressure and still maintain accuracy.
Hiring organization
Employment Type
Full-time
Job Location
Date posted
September 17, 2024
PDF Export
