Utilization Review Manager - Baroness Hospital - Full-time

Job Summary:
The person in this position is responsible for the daily management and supervision of the Utilization Management staff. In the absence of the Care Transitions manager this would include case management and discharge planning. The manager must have thorough knowledge of hospital care management and broad working knowledge of managed care, health related government regulations including Medicare and Medicaid and commercial insurance requirements. Adjustments to supervisory responsibilities may be made by the Director to meet organizational needs.

Education:
Required:
Graduate from an accredited School of Nursing. Bachelor Degree in Nursing (BSN) or BS in related field. Associate degree may be considered if the applicant has extensive utilization management/case management background.

Preferred:
Master's Degree in Business or health related field

Experience:
Required:
At least five (5) years varied experience as a clinician, demonstrated leadership skills, previous supervisory roles, computer literacy a must, hospital utilization management and/or case management experience required.

Preferred:
Additional experience w/ commercial, Medicare or Medicaid providers

Position Requirement(s): License/Certification/Registration
Required:
Current Licensure to practice nursing in the State of Tennessee.

The Nurse Licensure Compact will not change how to obtain or renew a Tennessee license. However, the Tennessee nursing license will be a single state license for Tennessee Residents or non-compact state residents. Tennessee licensure or multistate licensure from a compact state must be obtained within three months of hire for non-Tennessee residents.

Preferred:
N/A
Department Position Summary:
The Manager of the Utilization Review Department demonstrates the leadership skills needed for the success of the department -The talent for setting meaningful priorities, an aptitude for teambuilding and expertise in effective communication. The Manager is accountable for the quality of the utilization reviews using nationally accepted standards, criteria and practice. The Manager is also responsible for the daily activities associated with utilization management to include billholds, coding queue, departmental appeals, observation tickets, DNFB report, UR staff assignment, monitoring of payer behaviors, (which are communicated back to JOC and the VP of Payer relations), maintaining a current knowledge of payer specific guidelines which are communicated back to staff through training and monitoring, and partnering with the revenue integrity department to maintain optimal appeal success. This position will sit on the UR committee and participate in the formulation of departmental UR policy to meet CMS requirements.