Newport News, Virginia
Responsible for providing leadership and direction to the Utilization Managers while providing for the judicious management of health system resources through advocacy for both the patient and the organization. Responsible for maintaining daily staffing and assignments, providing regulatory oversight of state and federal notices, and is a resource for challenging and complex cases. Subject matter expert on medical necessity reviews and payor contracts for all patients hospitalized at Riverside facilities in accordance with national guidelines and standards of excellence, in accordance with the UM Plan established by Riverside Health System, facility goals, and strategic plans.
What you will do
- Ensures department aligns practice with Riverside’s mission and vision. Advances the application of research and evidence-based practices through the expert use of MCG national guidelines when assigning levels of care to hospitalized patients. Communicates effectively and professionally regardless of modality. Provides education regarding utilization management to patients, families, and other members of the care team as needed. Maintains current knowledge of health care economics, trends, and reimbursement methodologies, and applies this knowledge to daily practice. Understands and shares with staff updates in healthcare economics and public policy as it applies to Utilization Management. Stays current via continuing education, MCG Interrater Reliability, and ACMA Compass modules.
- Manages the daily operations of the department. Participates positively in hiring, oversight, training, and support of all team members. Completes accurate staff evaluations in a timely manner. Promotes satisfactory staff retention and is competent in labor relations matters. Seeks guidance from Director and HR in sensitive or complicated matters. Contributes to decision-making and decision support as a member of the interdisciplinary team
- Respects and incorporates patients’ goals of care and treatment preferences while respecting available resources. Builds and maintains relationships that foster trust and confidence. Engages with physician leaders to provide education and promote optimal patient care. Routinely collaborates with members of the interdisciplinary team, Physician Advisors, and facility leadership.
- Advocates on behalf of patients/family/caregivers for service access or creation and for the protection of the patient’s health, well-being, safety, and rights. Promotes and engages in culturally competent care. Partners with providers and payers to ensure the patient can access their full benefits. Demonstrates the ability to balance resources with patient preferences. Advocates for Riverside regarding compliance with the administration of required notices when medical necessity does not exist and ensures the patient/family is in complete understanding.
- Manages cost of care with the benefits of patient safety, clinical quality, risk, and patient satisfaction to provide recommendations and decisions that ensure optimal outcomes. Continuously improves the delivery and outcomes of comprehensive, quality, personalized patient/customer care economically and in accordance with patient safety standards, standards of excellence, and the Riverside Code of Conduct. Applies knowledge of contractual arrangements and payment models to daily practice. Assists the Director in meeting or exceeding annual revenue budget.
- Embraces and incorporates innovation and technology to improve collaboration and patient outcomes. Ensures team is compliant with organizational policy and regulatory requirements to securely transmit patient information and protect their health information.
- Coordinates monthly audits (RN, MCG, & OBS notification compliance) and distributes as appropriate.
Qualifications
Education
- Associates Degree, Nursing (Required)
- Bachelors Degree, Nursing (Preferred)
Experience
- 5-6 years Clinical Nursing experience (Required)
- 3-4 years Utilization Management experience (Required)
- 2 years Supervisory experience (Preferred)
Skills and Abilities
- Excellent verbal and written communication skills.
- Excellent interpersonal skills.
- Excellent organizational skills and attention to detail.
- Ability to act with integrity, professionalism, and confidentiality.
- Proficiency with computer systems required to perform the job.
Licenses and Certifications
- Registered Nurse (RN) - Virginia Department of Health Professions (VDHP) (Required)
- Accredited Case Manager (ACM) - American Case Management Association (ACMA) within 1 Year() or
- Certified Case Manager (CCM) - Commission for Case Manager Certification within 1 Year()
To learn more about being a team member with Riverside Health System visit us at https://www.riversideonline.com/careers.