What are the responsibilities and job description for the Manager, Field Based Medical Staff Operations position at Great Oaks Recovery Center?
Job Summary
The Utilization Management Manager is responsible for overseeing the daily operations of the UM department. This includes leading and facilitating reviews of assigned admissions, continued stays, utilization practices, and discharge planning according to approved clinically valid criteria.
Key Responsibilities
- DIRECTS AND MANAGES: Day-to-day operations and supervision of staff to ensure coverage for clients.
- MONITORS PROGRESS: UR cases and insurance appeals, problem solves when necessary, and mitigates all issues with utilization.
- OPTIMIZES REIMBURSEMENT: For the facility while maximizing use of the client's provider benefits for their needs.
Staff Supervision
Assigns all clients to Utilization Review staff and supervises staff to ensure they are completing insurance verifications on time and compliant with regulatory standards and requirements.
Training and Development
Leads a team of highly engaged members through hiring, orienting, performance assessment and management, motivating, training, scheduling, and coaching to meet department goals and ensure effective and efficient department operation.
Client Admission Reviews
Reviews application for client admission and approves admission or refers case to utilization review committee for review and course of action when case fails to meet admission standards.
Insurance Verification
Chart Analysis
Analyzes client records to determine appropriateness of admission, treatment, and length of stay to comply with government and insurance company reimbursement policies.
Communication and Coordination
Ensures charting deficiencies are minimized and corrected timely by responsible staff. Identifies and forwards charts for review based on outlying data to the Medical Director.
Quality Assurance
Assists review committee in planning and holding mandated quality assurance reviews.
Liaison Role
Acts as a liaison between Medicaid reviewers and the staff completing required paperwork to facilitate the Utilization Review process.
Qualifications
Graduation from an accredited school of nursing OR a Bachelor's degree in social work, behavioral or mental health, or other related health field required. Master's Degree in same field preferred.
Four or more year's clinical experience with the population of the facility and previous experience in utilization management required.
Two or more years' experience in medical/psychiatric utilization management required.
A comprehensive understanding of the admission, concurrent, continued stay, and retrospective reviews using the established facility criteria.
The ability to communicate professionally and effectively with multidisciplinary team members, managed care organizations, and business office, providing needed information in a logical, concise manner using technical language that accurately describes client's condition.
Current licensure as an LPN or RN or current clinical professional license or certification, as required, within the state where the facility provides services.
CPR and de-escalation certification required (training available upon hire and offered by facility).
Veterans and military spouses are highly encouraged to apply.
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