Manager of Utilization Review and Case Management Professional Development

Facilitate team meetings that foster interdepartmental collaboration with the Case Managers and Social workers as deemed necessary

Participates in multidisciplinary meetings and Utilization Review/Case Management meetings. Provides input in such meetings

regarding utilization management and discharge planning.

Responsible for evaluating and screening potential admissions to the facility 

Knowledgeable of criteria for Medicare, Medicaid, HMO and private insurance coverage.

Communicate daily with admissions personnel regarding admissions and discharges to various units.

Cooperate with insurance companies, based on information received.

Ensures that the UM System is maintained or surpassed by collecting quality indicators and variance data and reporting the data to the appropriate department; reports and identifies data that indicates potential areas for improvement of care and services provided within the system.

Educates physicians and staff regarding appropriate level of care/utilization issues.

Develop and implement methods, policies and procedures to improve the departments efficiency and overall effectiveness.

Oversight and evaluation of the discharge planner/ utilization review nurses.

Perform and oversee needs analysis and planning.

Work with executive leadership to ensure targets are met for the annual

operating plan/financial management.

Ensures confidentiality of all patient information encountered 

Document patient screening, Ensure that appropriate referrals are made and documented.

Prepares qualitative and quantitative reports related to UR activities

Participates in related training and professional development to develop competencies in utilization review

Assures completion of new employee training and competency

Identifies and documents educational needs of individual department members

Reviews and identifies deficiencies (i.e. Incomplete or inaccurate insurance reviews) and takes corrective action, as required..

Actively involved in measuring case manager performance and communicates results and trends to supervisor.

Actively participates as an interdisciplinary team member of all UR related activities

Provides feedback to supervisor on ongoing basis in regard to concerns, improvements, changes, etc.

Identifies areas needing improvement and utilizes the facility performance improvement process. Actively participates in department processes as required.

Brings to the  Directors attention significant issues related to the processes 

Assists with special administrative tasks and projects to facilitate improved patient care and Case Management program evaluation as required.

Exhibits willingness to master new skills and accepts change as necessary within the department.

Participates in Quality Improvement activities as needed to continually improve their departments performance.

Demonstrates working knowledge of the job by seeking guidance and direction as necessary for optimum performance of daily assigned duties.

Continually strives to make productive use of time through careful coordination of daily tasks, setting priorities, and reducing non-essential interruptions in order to complete the job during the allocated time.

Interacts and communicates with others in a way that promotes a positive and cooperative work environment.

Demonstrates initiative and enthusiasm in performing job duties on a daily basis.

Consistently maintains composure and professionalism during difficult situations.

Demonstrates understanding of concepts of excellence in customer service and conducts duties in positive, customer-friendly manner to all customers of department, particularly patients, visitors, physicians, and other employees.

Performs other duties as assigned by the Case Management Director in a timely manner.

Displays a positive attitude and outlook (verbal and nonverbal body language).

Attitude toward change: Works effectively in a variety of situations, recognizes the need for change, can cope with its threatening aspects, and puts its positive aspects to good use.

Customer Service Skills: Able to successfully manage customer experiences.

Teamwork: Works in the spirit of cooperation and collaboration to achieve mutual goals.

Initiative: Able to know what needs to be done and takes action, striving for the highest level of job performance.

Time Management: Able to organize work and use time effectively.

Integrity: Acts in accordance with principles of honesty, fairness, and trust in all work relationships.

Respect and Caring: Treats others with interest, concern and compassion; respecting differences in style, approach, and background.

Accountability: Able to take responsibility for ones actions.

Interpersonal Skills: Maintains positive work relationships.

Communication Skills: Able to convey ideas and information clearly.

Feedback: Able to accept constructive feedback and integrate into performance.

Flexibility: Able to redirect day-to-day activities based on departmental/organizational needs.

Problem Solving: Offers solutions to problems, when appropriate.