UM Manager-Onsite

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

About the Role

Responsible for providing leadership and managing all processes/services within the Utilization Management program. Assumes responsibility for implementing standards of practice, evidence-based medical guidelines, departmental policies and procedures, and maintaining and guiding the quality of patient care delivered. Ensures staff and program compliance with CMS and other payer regulatory compliance and Utilization Review standards, practices, and procedures.

Responsible for financial performance, human resource management, and staff engagement, appropriate reporting, and coordinating program functions with physicians and other hospital departments to assure optimal program quality outcomes and patient throughput are achieved. Creates an environment that enables the system to fulfill its mission and goals, fosters communication, and collaborative practice with physicians and other departments. Participates and supports the UM Committees within the hospital and/or other hospital committees to ensure program requirements are met.

Responsibilities

• Customer/Employee Satisfaction
  • Promotes a positive environment for patients, families, staff, and the community.
  • Responds to inquiries and complaints effectively and in a timely manner; promotes a positive, professional image serving as a liaison between staff, physicians, and administration.
  • Demonstrates commitment to teamwork through positive interactions and feedback to/from subordinates, physicians, peers, and other customers.
  • Accepts responsibility for employee morale and team performance toward goal achievement; develops measurable team goals, monitors progress, and keeps staff abreast of progress.
  • Utilizes department metrics and develops plans to direct departmental practice performance initiatives, staff satisfaction initiatives, and improvements in physician relations and overall customer service.
  • Represents WellStar by exhibiting values and credo.
• Coordinates Patient Care
  • Continually assesses current trends, clinical, and technological advances in best practice and takes appropriate action to improve outcomes and cost-effective care.
  • Reviews and updates department/program-specific standards, policies, and procedures to assure compliance with established standards and current practice.
  • Oversees the daily operation of the program in collaboration with physicians and senior leadership.
  • Assesses, provides for the delivery of, and evaluates the quality of services delivered within the program.
  • Ensures all staff collaborates with Discharge Planners to deliver services more cost-effectively in the most appropriate setting to meet patient needs and communicates these needs with payers.
  • Serves as an expert for payer requirements and communications to hospital staff, personnel, and other healthcare professionals within the organization and community.
  • Demonstrates advanced knowledge and practice in the assessment, diagnosis, treatment, and evaluation of human responses to actual and/or potential health problems via role modeling and consultation.
  • Consults with healthcare providers, ancillary services, patients, and significant others to assess and identify individual patient care needs.
• Education/Outcomes Management
  • Develops, revises, and maintains education materials.
  • Communicates with MD offices in the admission process and obtaining authorizations.
  • Serves as a clinical resource for staff development.
  • Acts as a resource for Utilization Review within the continuum of care.
  • Sustains professional competency; pursues clinical skill development and specialty certification.
  • Facilitates case management across the pathway to assure seamless integration of care.
  • Develops an outcome scorecard for benchmarking the program.
  • Identifies performance improvement (PI) opportunities to achieve compliance with best practices.
  • Tracks, trends, and analyzes data; defines opportunities for improvement from data analysis.
• Utilization Review
  • Assumes responsibility for ongoing program coordination across the continuum from admission through discharge and all associated follow-up.
  • Maintains competency in criteria review guidelines; ensures Utilization Review competencies are completed annually.
  • Analyzes, interprets, and makes recommendations based on Utilization Review Reports, productivity data, and financial measures.
  • Serves as a liaison between clinical departments by analyzing individual department performance about established goals.
  • Ensures compliance with CMS/commercial payor standards to maintain contract compliance and participates in JOC Meetings.
• Fiscal Accountability
  • Assists with the development and implementation of operational and capital budgets consistent with system-wide, facility/divisional goals and objectives.
  • Assists with the establishment of productivity measures and facilitates program and team achievement of established goals.
  • Maintains FTE, salary, and expense budgets at or below budgeted levels; demonstrates the ability to review and analyze current and historical data relevant to budget variances.
  • Assists with the development of collaborative approaches that promote quality, cost-effective utilization services across the continuum.
• Liaison for Regulatory Compliance
  • Coordinates with leadership on compliance and regulatory standards as well as contractual guidelines.
  • Develops and implements professional standards for the program based on recognized standards of care, Joint Commission and CMS standards, state/federal regulations, and system policies and procedures.
  • Monitors staff compliance with regulatory standards.
  • Serves on hospital and system committees as needed.
  • Participates in identifying learning needs for the Utilization Review Team; assures staff competencies on an annual basis.
  • Makes staff aware of community outreach and educational opportunities.
  • Represents the team at local, state, and national meetings through educational offerings and involvement in professional organizations.
  • Demonstrates motivation for learning through independent reading, professional networking, and communicates professional expertise through publications and presentations at the local, regional, and national levels.

Performs other duties as assigned and complies with all WellStar Health System policies, standards of work, and code of conduct.

Requirements

• Education
  • Bachelor’s in Nursing or Diploma in Nursing (required).
  • Master’s in Nursing (preferred).
• Licenses & Certifications
  • RN - Registered Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact (required upon hire).
• Experience
  • Minimum 3 years of experience in the management of a multidisciplinary staff in the field of case management (required).
  • Minimum 3 years of experience in a hospital environment (required).
  • Will consider years of experience in case management in lieu of a Master’s degree.
• Skills
  • Strong communication and interpersonal skills.
  • Ability to multitask and handle change in a fast-paced environment.
  • Excellent time management skills and ability to prioritize.