Registered Nurse-Utilization Management Specialist
Job Objective: A brief overview of the position.
Under the direction of the Director of Case Management, the Utilization Management Specialist improvement initiatives. The role includes appealing all clinical denials and providing support for non-clinical appeals and to Case Management staff for utilization issues. In addition, the Utilization Management Specialist will be responsible for the collection, analysis, education and dissemination of information to improve service to patients/members, their families, and all staff members.
DIRECTOR, CASE MANAGEMENT
Minimal/ No Potential
Required: BSN or MSN or enrollment in an RN-BSN or RN-MSN program within 1 year of hire and completion within 5 years of hire if hired after July 1, 2012
Required: Registered Nurse in the State of California
Preferred: UM Certification
Required: 5 years Case Management experience
Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
Demonstrates initiative by assisting Case Management Staff with Utilization Review issues, high risk cases and in initiating Denial Letters to Medicare Patients under CMRI Guidelines.
Oversees Medi-Cal TAR Program to facilitate timely authorizations
Prepares, analyzes and presents UM outcome data (including denial measurement) and recommendations that is accurate, valid and reliable.
Achieves improvement in financial performance by prioritizing, initiating and processing inpatient clinical denial appeals appropriately and timely.
Educates departments on issues related to clinical denials and related utilization of service issues to reduce clinical denials: dollars and number of days.
Provides educational programs to various multidisciplinary staff regarding denials management and issues related to utilization of services and new processes at least on a quarterly basis.
Meets department productivity targets and EMH financial performance indicators.
Assists Service Line Case Managers and intervenes with complex utilization management issues.
Oversight of on-site reviewers including obtaining and providing information that is requested.
Demonstrates accountability by embracing job description obligations and taking initiative and ownership of the job responsibility tasks.
Identifies relevant and valid clinical, financial and process measures from which to assess clinical denial outcomes.
Develops cost analysis conclusions based on research and financial data in close collaboration with the Business Office/Patient Financial Services staff.
Analyzes, disseminates, and presents hospital outcomes data using statistical tools to the Utilization Management Committee, working in collaboration with the Chair of the committee.
Prepares Utilization Management Committee packet and meeting minutes.
Participates in committees: receives information and reports outcome information.
Communicates with team members.
Implements tracking systems to measure the effectiveness of interventions.
- Other duties as assigned.