RN Nurse Manager Utilization Review

This position will manage activities and staff of the Utilization Review and Clinical Documentation Improvement departments.

Supervise and evaluate the daily work of these teams in accordance with departmental and organizational policies. Provide education within the departments and the organization at large on clinical care, levels of care, and financial issues. Analyze and report data related to case management activities, payer activities, resource utilization, and clinical denials. Lead hospital wide initiatives on behalf of the department.

Monitor the performance, collection and analysis of data to report on the effectiveness of process improvement to the organization and department. Participate in the planning, development and implementation, and ongoing success of the Clinical Documentation Management Program. Educate members of the patient care team regarding documentation guidelines, including attending physicians, nursing, and other interdisciplinary team members.

Qualifications:
Minimum Education
Master's Degree (Required)

Minimum Work Experience
7 years Healthcare experience (Required)
3 years Supervisory experience (Required)

Required Skills/Knowledge
Facile with keyboarding and familiar with software such as Windows environment (i.e., Microsoft Office, Word, PowerPoint, Excel, Access).
Excellent oral and written communication skills. Knowledge of children's health issues.
Knowledge of cultural issues and their impact on health care. Strong focus on Service Excellence.
Working experience with medical management criteria such as Milliman and/or Interqual.
Ability to analyze and present productivity and outcome data using Microsoft Access and Excel.

Required Licenses and Certifications
Registered Nurse in District of Columbia (Required)Basic Life Support for Healthcare Provider (BLS) (Required)
CCDS or CDIP (Preferred)
Case Management Certification (CCM or CMSA) (Preferred)

Functional Accountabilities
Operations Management - General

• Supervise and evaluate the daily work in accordance with departmental and organizational policies.

• Manage staffing to ensure adequate coverage and optimize productivity. Assign coverage and deploy staff accordingly.

• Participate in budget development and recommend budgets for areas of oversight.

• Track spending for areas of oversight.

Operations Management - Clinical Resource Management (CRM)/Utilization Review (UR)

• As a subject matter expert on Interqual and MCG guidelines, function as a resource to staff and intervene to resolve issues that arise internally and with payors.

• Mentor staff and support learning opportunities to foster success.

• Work directly with payors and Managed Care to enhance communication and improve authorization processes.

• Assist with the management of denials and High Risk cases.

Operations Management - Clinical Documentation Improvement (CDI)

• Partner with coding leadership to monitor trends and mismatches between CDI and coding and strategize about ongoing process improvement.

• Ensure Clinical Documentation Specialists and Coders are educated on organizational initiatives and professional trends in practice.

• Target improvement activities to specific payers, DRGs, and teams based on financial and clinical data analysis.

• Assist in the development and reporting of performance measures to the medical staff and/or healthcare teams; prepare physician specific-data reports.

• Facilitate change process required to capture needed documentation such as template/forms design.

• Develop ongoing physician/provider education strategies in collaboration with other Revenue Cycle Departments to promote complete and accurate clinical documentation and correct negative trends.

• Monitor CDS assignment in 3M/360 and review Account Validation.

Relationship Building/Information Sharing

• Establish and maintain effective internal and external relationships to optimize achieving departmental and organizational goals.

• Provide information to Case Managers and Clinical Documentation Specialists on organizational initiatives and professional trends in practice.

• Represent CRM and CDI on organizational committees.

Performance Improvement/Outcomes Management

• Ensure Case Management and Clinical Documentation Improvement activities are in regulatory compliance (JC, CMS).

• Track clinical, functional, operational, quality and financial data related to CRM and CDI.

• Collect and analyze data on program efforts and outcomes; identify patterns, trend variances, and opportunities to improve documentation review and process.

• Implement processes to continually improve performance, reduce denials, and optimize reimbursement.

• Update Departmental procedures to reflect changes in payor contracts and departmental processes.

Organizational Accountabilities
Organizational Accountabilities (Staff)
Organizational Commitment/Identification
Teamwork/Communication
Performance Improvement/Problem-solving
Cost Management/Financial Responsibility
Safety