Case Management/Utilization Review Manager

SUMMARY

The Case Management/UR Manager assumes responsibility to direct, plan and supervise activities of case management function involved in following patients throughout continuum of care to ensure optimum utilization of resources, service delivery and compliance with external requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned

1. Actively work as a Case Manager/Utilization Reviewer with clinical experience to direct continuum of care for the patients and be fiscally responsible in the care.

2.Direct, plan and supervise activities of case managers, utilization reviewers and discharge planners in following patients throughout the continuum of care to include strategic planning and daily management of operations related to case management for all inpatient units; ensure optimum utilization of resources, service delivery and compliance with external requirements.

3. Plan, schedule and organize work for staff ensuring proper distribution of assignments and efficient utilization of personnel, space and facilities; direct the requisition, care and maintenance of department inventory.

4. Participate in multidisciplinary team meetings regarding the planning and implementation of patient care; facilitate communication and problem solving related to discharge planning.

5. Maintain required records, reports and statistics for administrative purposes; ensure compliance with established hospital policies, procedures, objectives, performance improvement, safety, environmental and infection control.

6. Maintain liaison with physicians, hospital administration and ancillary department managers to analyze unit needs, identify problems and effect change as needed to improve services.

7. Determine fiscal requirements of department and prepare budget recommendations. Monitor, verify and reconcile expenditure of budgeted funds.

8. Direct various personnel actions including, but not limited to, hiring, performance evaluations, disciplinary action and scheduled time off.

9. Actively participate in the Utilization Management Committee and provide monthly statistical activity report.

10. Investigates over and underutilization cases, implements corrective action and reviews all denial letters for reconsideration appeal.

11. Performs other duties as assigned.

12. Performs other related duties as assigned.

COMPLIANCE RESPONSIBILITIES

•    Understands and adheres to Loretto Hospital’s compliance standards as they appear in the Compliance Policy, Code of Conduct and Conflict of Interest Policy.
•    Keeps abreast of all pertinent federal, state and Hospital regulations, laws, and policies as they presently exist and as they change or are modified.
•    Ensures that the staff are trained and evaluated on their knowledge of and adherence to compliance policies and procedures specific to their jobs.

JOB REQUIREMENTS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed must be representative of the knowledge, skills, minimum education, training, licensure, experience, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Registered Nurse with current license AND Bachelor's Degree in Health Related field.
2. At least five years progressive experience in utilization management, discharge planning and/or case management.
3. Exceptional communication and leadership skills, demonstrates good work ethic, and analytical skills
4. Extensive knowledge of community resources.
5. Demonstrates considerable knowledge of payor requirements and criteria sets.
6. Extensive knowledge of regulatory requirements, including but not limited to, JCAHO, HFAP, IDPH and CMS.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.

For purposes of the American with Disabilities Act, “Job Duties” are essential job functions.

PHYSICAL DEMANDS:

While performing the duties of this job, the employee is frequently required to sit, stand and walk as well as occasionally stoop, kneel, crouch or crawl. Using proper body mechanics, the employee may be expected to lift, pull, push or move patients and/or equipment. Fine motor skills are required when using hands and fingers to handle, feel or reach. Normal or corrected vision, hearing and ability to speak are necessary. Specific vision abilities required include close vision, sharp eye focus and ability to distinguish colors. There will be periods of stressful intense concentration with more than average pressure used in a variety of problem solving situations.