Overview

The Clinical Manager of the Utilization Management (UM) Department oversees the daily operations of the UM team. This position manages the Utilization Review Staff and ensures compliance with regulatory requirements related to the appropriateness and medical necessity of care provided. The Manager provides input to the Director of Revenue Cycle regarding daily strategic decisions that affect the UM department.

This role maintains a commitment to excellent customer service consistent with the Vision, Mission, and Values of Covenant HealthCare and the commitment to Extraordinary Care for Every Generation.

Responsibilities

Serves as the immediate manager for Utilization Review staff.

Responsible for daily operational management, supervision of staff, budget preparation and monitoring, and other management duties.

Accountable for strategic planning, implementation, evaluation, and revision of systems that support UM department and organizational goals.

Maintains 24-hour accountability for UM functions.

Assists with developing and implementing UM programs and daily scheduling of all staff.

Evaluates and assesses patient care data to ensure that care is provided in accordance with CMS Conditions of Participation and clinical guidelines by ensuring staff use appropriate and Covenant endorsed- tools.

Provides leadership and direction in the daily operational activities of UM by assuring activities are appropriately assigned, resources are available, and requirements of external entities such as regulatory and third-party- payers are met.

Ensures that department objectives and metrics are achieved timely and on target according to identified goals, including the four pillars of success.

Communicates issues and concerns affecting the department's capacity to achieve results with Revenue Cycle leadership and proactively assists with crafting solutions.

Assigns tasks according to priority and supports staff in carrying out activities to reach identified goals.

Ensures that department needs are identified, analyzed, and responded to in a timely manner.

Responsible for final oversight of payroll, performance evaluations, and corrective action.

Performs other duties as assigned.

Resource to Coding/CDI for review as needed

Resource to IP Case Management team. Participates in LOS discussions

Develop and Maintain Utilization Committee in accordance with appropriate regulatory requirements

Maintains knowledge and access to payor information to facilitate dissemination to staff.

Resource to Billing / Denials Management as needed.

Qualifications

EDUCATION/EXPERIENCE REQUIREMENTS

Bachelor's Degree preferred.

Licensed RN in the State of Michigan required.

Experience in Utilization Management and/or Clinical Documentation Improvement required.

Minimum three (3) years of supervisory/management experience preferred.

Minimum of five (5) years of experience in a patient care acute setting preferred.

KNOWLEDGE/SKILLS/ABILITIES

Working knowledge of navigating patients through procedures and across the continuum of care.

Experience with continuous performance improvement preferred.

Ability to communicate effectively, both written and verbal communication, with persons of various cultural and educational backgrounds, including patients, families, staff, leadership and physicians.

Demonstrates knowledge of utilization review and clinical documentation improvement.

Maintains professional development through seminars, workshops, in-service activities and current professional literature

Excellent organizational skills and ability to effectively coordinate all aspects of patient care.

Ability to be an active, participatory member the interdisciplinary team.

May be required to participate in on-call activities after hours and weekends.

Full command (written and verbal) of the English language.

WORKING CONDITIONS/PHYSICAL DEMANDS

Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards.

Frequent walking, sitting, talking, and hearing.

Occasional lifting, standing, carrying, pushing, pulling, climbing, stooping, reaching, handling, and fingering.

Occasional near vision, midrange vision, far vision, color vision, and field of vision.

Occasional lifting 0-50 lbs.

RN CLINICAL MANAGER - UTILIZATION MANAGEMENT (UM)