Utilization Management Manager

General Summary

Leads and shapes the Utilization Management (UM) Strategy for Bryan Medical Center (BMC) while providing management oversight in implementing, directing, and monitoring the UM Department functions, including prior authorizations, concurrent review, medical claims review, and appeals and grievances. Directs the UM Department, acts as a subject matter expert, and provides executive level advice and guidance on the Department’s functions and overall business operations. Directs, manages and supervises UM Department staff.

Principal Job Functions

• Commits to the mission, vision, beliefs and consistently demonstrates our core values.
  • Develops, leads and directs the UM Strategy for BMC, while providing management oversight in implementing, directing and monitoring the UM Department functions, including prior authorizations, concurrent review, medical necessity, denial claims review, and pre-bill appeals. In collaboration with Revenue Integrity, works to appeal post payment denials originating from UM areas of responsibility.
  • Serves as the contact person for the relationship with the Physician Advisor or Physician Advisor partner. Identifies opportunities to create efficiencies in the UM program and activities, incorporates innovative approaches and solutions, and leads process redesign work necessary to implement improvements.
  • Provides leadership in the design and implementation of UM policies, processes and procedures needed to meet NCQA and URAC accreditation and other regulatory and compliance requirements.
  • Ensures contractual turnaround times are met by staff and performs duties associated with Prior Authorization. Reviews and reports out on UM trends. Ensures quality of services through UM, review of medical records and provider education, while identifying training opportunities and trends.
  • Designs, develops, implements, and maintains programs, policies and procedures in order to meet regulatory, contractual, accreditation, and performance standards. Maintains knowledge of UM software programs (Epic, InterQual & MCG) functionality and leads the clinical team responsible for advising on replacement, upgrades, and user testing.
  • Advises and collaborates with the Chief Medical Officer (CMO) and Medical Directors on strategic issues involving UM Department programs.
• Ensures that staff advocates for proper placement within the scope of the role of the UM by arranging for, or directly reaching out to, Primary Care Providers (PCPs), specialists, hospitals, local mental health services, the managed care behavioral health organization (MCBHO), local care management programs, and community agencies to maximize UM’s outcomes.
• Oversees UM Department preparations and responses to regulatory audits and the construction of corrective action plans. Participates in regulatory audits related to all aspects of utilization management.
• Tracks, analyzes, and develops strategies to address outlier performance of utilization metrics and reports on metrics at a regular cadence. Develops performance measures related to strategic goals and new projects and presents to staff and Leadership as directed.
• Maintains current knowledge of relevant Federal and State laws, policies and directives, and organizational policies and procedures. Reviews and assesses overall department functions, core work, goals, and structure. Develops and implements short- and long-term planning to achieve strategic objectives, and completes an annual department assessment.
• Oversees, coordinates, or participates in a variety of committees. Prepares effective reports and participates in monthly UM committee meetings. Reports periodically at various Clinical Committee meetings.
• Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
• Performs other related projects and duties as assigned.

Required Knowledge, Skills And Abilities

• Knowledge of Utilization Management processes and desirable outcomes.
  • Knowledge of budget/financial management principles and practices.
  • Knowledge of the principles and practices of general personnel management, labor laws and applicable regulations related to healthcare employment and staffing.
  • Knowledge of staff scheduling methods and processes.
  • Knowledge of federal and state regulations related to healthcare and practice/service areas.
  • Knowledge of computer hardware equipment and software applications relevant to work functions.
• Skills in supervising, mentoring, instructing and evaluating the work of professional and other service/unit staff.
  • Ability to lead, motivate, and develop a high-performing team.
  • Strong project management, process improvement, and organizational skills.
  • Ability to promote change toward the achievement of a shared vision, challenge current paradigms and facilitate systems thinking.
  • Ability to act in a proactive manner while also providing crisis/situational management in an erratic and potentially unpredictable work environment.
  • Ability to balance and prioritize diverse management and clinical responsibilities.
  • Ability to maintain confidentiality of patient and organizational information.
  • Ability to establish and maintain effective working relationships with health care team members, management and diverse patient/family populations.
  • Ability to drive to results.
  • Ability to communicate effectively both verbally and in writing.
  • Ability to maintain regular and punctual attendance.

Education And Experience

• Bachelor’s degree in nursing, other clinical field, or healthcare related field such as management, health service administration. Master’s degree in a related field such as nursing, business or health services administration preferred.
• Minimum of five (5) years recent clinical experience required. Prior Utilization Management experience preferred. Prior supervisory or management experience preferred.
• OR Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act required.