Manager Utilization Review/Case Management CMC - Carole Young

About the role

The mission of Correctional Managed Care is to address the healthcare needs of underserved patient populations within the Texas Department of Criminal Justice (TDCJ) and the Texas Juvenile Justice Department (TJJD). The Manager for Correctional Managed Care Utilization Review has responsibility for daily department operations, including management of Utilization Review Case Managers to support optimal department functionality, exceptional customer service, and patient support.

Responsibilities

• Supervise operational management of the Utilization Review program to ensure high-quality, cost-effective service/outcomes and a safe, efficient work environment
• Monitor work performance of URCM staff and provide guidance and intervention to assist staff in achieving department and individual goals
• Prepare department work schedules and timekeeping, ensuring adequate staff coverage and completion of work
• Provide back-up support for telephone UR to ensure adequate staff coverage
• Provide leadership to the department and promote teamwork
• Assist in implementation of UR policies and procedures
• Assist with identification of department SOPs, flow diagrams, and job aids needed
• Responsible for orientation of new personnel and integration into the department as fully trained Utilization Review Case Managers
• Act as an expert resource for clinical resources including Optum (InterQual), Urgent Referral guidelines, and others as defined by CMC
• Review quality of care issues that may arise during department duties and identify areas of potential medical liability
• Contribute to the overall success of UTMB Correctional Managed Care
• Adhere to internal controls and reporting structure established for the department
• Perform other related duties as required

Requirements

• Graduate from an accredited school of professional nursing
• Current Texas nursing licensure as a professional registered nurse
• Minimum of five years full-time wage-earning experience as a professional nurse in a health care setting
• At least two years in utilization review and/or case management experience
• Two years of supervisory and/or management experience

Preferred qualifications

• Master’s Degree
• At least three years of adult care nursing experience

Licenses & certifications

• Active and valid nursing license in Texas

Supervision

Received: Director, CMC Utilization Review
Given: Utilization Review Case Manager, CMC

Decision-making responsibility

• Budgetary decisions
• Personnel
• Data analysis and planning
• Management of emergency situations
• Quality Improvement

Equipment

Standard office equipment

Work environment

Standard office environment. May be required to work within the confines of a prison, jail, or juvenile detention center. Security clearance is required; pre-employment drug testing is also required.

Knowledge, skills & abilities

• Remain current on job-related knowledge, skills, and in-service/certification requirements as deemed appropriate for the position
• Take initiative and be willing and able to learn multiple aspects of the job
• Demonstrate collaboration, professionalism, and ability to work with all health care providers and staff
• Perform a variety of marginal, clerical duties not listed but determined as needed
• Support the department as both an active participant and a leader
• Manage crisis situations professionally and effectively
• Prioritize work effectively
• Communicate clinical issues excellently to non-nursing utilization review staff
• Actively participate in performance improvement and act as a leader in achieving department goals