Description

ESSENTIAL FUNCTIONS:

• Monitor utilization of services and optimize reimbursement for the facility while maximizing use of the patient’s provider benefits for their needs.

• Conducts and oversees concurrent and retrospective reviews for all patients.

• Act as a liaison between Medicaid reviewers and the staff completing required paperwork to facilitate the Utilization Review process.

• Collaborates with physicians, therapist and nursing staff to provide optimal review based on patient needs.

• Collaborates with ancillary services in order to prevent delays in services.

• Evaluates the UM program for compliance with regulations, policies and procedures.

• May review charts and make necessary recommendations to the physicians, regarding utilization review and specific managed care issues.

• Provide staff management to including hiring, development, training, performance management and communication to ensure effective and efficient department operation.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• Bachelor's Degree in nursing or other clinical field required. Master's Degree in clinical field preferred.

• Six or more year's clinical experience with the population of the facility preferred.

• Four or more years’ experience in utilization management required.

• Three or more years of supervisory experience required.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

• If applicable, current licensure as an LPN or RN within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.

Qualifications

Skills

Required

• Leadership: Expert

• Communication: Expert

• Attention to Detail: Advanced

• Computer - Excel: Advanced

• Typing: Advanced

Behaviors

Required

• Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well

• Dedicated: Devoted to a task or purpose with loyalty or integrity

Education

Required

• Bachelors or better in Human Services

Licenses & Certifications

Required

• Reg Nurse

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)