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Manager Utilization Review RN

Company: Baylor Scott & White Health
Location: Temple
Posted on: January 7, 2022

Job Description:

JOB SUMMARY

The Manager Utilization Review RN provides leadership, strategic oversight, and monitoring of Utilization Review (UR) staff and programs, including the delivery of care coordination in all lines of business, management of targeted populations, expediting movement of members through appropriate levels of care, the evaluation of programs, improving programs, and creating new programs. Ability to assess and improve workflow and system configuration to meet regulatory and business requirements.

ESSENTIAL FUNCTIONS OF THE ROLE

Directs the daily operations of the Care Coordination Division related to all aspects of Utilization Management, Case Management, Disease Management, to include the staff, system, supplies, budget.

Ensures that work completed meets regulatory provisions and division policy and procedures.

Coordinates across SWHP, the system and across external entities the appropriate levels of health care services and communication to provide the highest level of service to members, providers, and other entities.

Finctions as a super user within the medical management system, requiring in-depth knowledge and understanding of how the system is configured.

Assesses impact of potential configuration changes, configure the system, create documentation and track the changes to meet standard system change requirements.

Establishes and continually improve policies, procedures, resources, auditing, and training to ensure business goals are met.

Promotes continuity of high quality care, as well as efficient utilization of health care resources by working collaboratively with the interdisciplinary teams through case management and discharge planning activities for plan members to expeditiously move patients through appropriate levels of care.

Manages and direct the delivery of continuing care to all members with special emphasis on the case management of specific targeted populations and members.

KEY SUCCESS FACTORS

Expertise in discharge planning, case management, utilization review and levels of care.

Strong written and verbal communication skills exhibiting professionalism in all encounters.

Understanding of healthcare systems and health plans.

Ability to learn and assess impact of change to medical management system to meet regulatory and business requirements.

Ability to make operational decisions around how work gets done - quality and productivity standards, measurable goals for employees and project teams, etc.

Ability to use broader objectives to determine how best to use resources to meet schedules and goals.

Ability to make or approve effective hiring and termination decisions.

Ability to evaluate and recommend changes to policies, and establish procedures that affect the managed organization.

Basic business knowledge, including but not limited to: annual planning and goal setting, adherence to budgets, employee compensation, compliance and risk management.

General computer skills, including but not limited to: Microsoft Office, information security, scheduling and payroll systems, electronic medical documentation, and email.

Masters degree (e.g., MA, MS, MBA, MSN, MSW) or equivalent (e.g., CPA, PE, etc.) preferred.

BENEFITS

Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level

QUALIFICATIONS

- EDUCATION - Bachelor's

- EXPERIENCE - 5 Years of Experience

- CERTIFICATION/LICENSE/REGISTRATION -
&nbspRegistered Nurse (RN)

Keywords: Baylor Scott & White Health, Temple , Manager Utilization Review RN, Executive , Temple, Texas

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