DIRECTOR, UTILIZATION MANAGEMENT - UNIVERSITY OF NEW MEXICO HOSPITAL - ALBUQUERQUE -

UNM Hospital; Albuquerque (NM); Presencial; USD 110 000 - 165 000; Tempo integral

Resumo da oferta

UNM Health is seeking a leader to manage the Utilization Management program at UNM Hospital, overseeing day-to-day operations and ensuring compliant, efficient use of medical resources. You will lead reviews, staffing, training, and develop performance improvements across neonate to geriatric care.

Qualifications include a Master’s Degree, NM RN license, CPR certification, and 4+ years’ experience with InterQual/MCG criteria.

Qualificações

• Experience with InterQual and/or MCG criteria (4+ years)
• RN license in NM or via reciprocal agreement
• CPR for Healthcare/BLS Prov or Prof Rescuers within 30 days

Responsabilidades

• Supervision: oversee department personnel, train and monitor work, manage staffing to fit needs
• Leadership: identify problems, plan improvements, hire/train/evaluate staff
• Budget: develop and monitor department operating budget
• Oversight: ensure utilization review from initial to concurrent review and denials
• Reimbursement: seek optimal reimbursement from government payers with proper authorization
• Quality: conduct quality reviews of utilization management processes
• Process improvement: develop and implement improvement action plans
• Collaboration: work with physicians, departments, patients, and payers to complete functions
• Data: collect and present data for units and committees
• Training: develop staff skills and conduct training
• Development: stay informed on regulations and build payer relationships
• Patient safety: follow safety policies and report issues

Conhecimentos

InterQual/MCG criteria

Formação académica

Master's Degree

Related Discipline (BSN required if not MSN)

MSN or DNP

Descrição da oferta de emprego

Compensation Disclaimer

Compensation for this role is based on a number of factors, including but not limited to experience, education, and other business and organizational considerations.

Department: Utilization Management - UH
FTE: 1.00
Full Time
Shift: Days

UNM Health provides the highest quality of care for more than 200,000 New Mexicans each year. In 1952, UNM Hospital was built on Native American grounds, with the promise to provide culturally competent and inclusive care to all New Mexicans. UNM Health is New Mexico's only Level I Trauma Center - a care for patients with the most complex conditions from across the state. Additionally, we are the first NIH-designated Comprehensive Cancer Center and award-winning Advanced Care Stroke Center. UNM Health providers specialize in over 150 areas of medicine and employ over 7,000 professionals. Together, we receive 900,000 outpatient visits, 22,000 surgical cases and 100,000 emergency room visits each year.

Position Summary

Manage the Utilization Management program at UNM Hospital, including direct oversight of day-to-day operations. Develop, implement and maintain the program to facilitate appropriate, effective and efficient use of medical resources. Lead review of activities, staffing, development and training. Ensure compliance with state, federal and other regulatory requirements. Ensure adherence to Hospitals and departmental policies and procedures. Patient care assignment may include neonate, pediatric, adolescent, adult and geriatric age groups.

Detailed Responsibilities

• SUPERVISION - Oversee the work of department personnel by training, allocating and monitoring work; evaluate performance and make recommendations for personnel action; oversees staff hours to best suit departmental and organizational needs
• LEADERSHIP - Provide leadership through identification of problems, opportunities for improvement, action planning, and implementation. Make personnel decisions to include interviewing, hiring, supervising, training, evaluating, disciplining and terminating department personnel
• BUDGET - Develop and recommend department operating budget and ensure that department operates within budget
• OVERSIGHT - Ensure utilization review is completed from initial review, concurrent review, managing denials, and other utilization management activities as assigned
• REIMBURSEMENT - Ensure optimal reimbursement from governmental third party payers, obtaining proper authorization
• QUALITY - Perform quality reviews of utilization management processes. Perform assessment, data collection and outcome criteria. Review and analyze information in collaboration with other team members as necessary and appropriate
• PROCESS IMPROVEMENT - Identify baseline outcomes; develop process improvement plans; prioritize and implement process improvement action plans; monitor and follow up on
• COLLABORATION - Ensures department collaborates with physicians, other departments, patients, families, insurance providers, and others as necessary to complete utilization management functions
• DATA - Collect, prepare, analyze and present valid, accurate and meaningful data in a variety of formats for various units, clinics, departments and committees
• TRAINING – Develop staff skills, competencies, and conduct staff training as necessary to improve departmental functions
• DEVELOPMENT - Maintain general knowledge of all areas of department and develop expertise in assigned areas; stays informed of regulations and regulation changes; develop and maintain relationships with third party payers, other departments, state offices, and other teams
• PATIENT SAFETY 1 - Follow patient safety-related policies, procedures and protocols
• PATIENT SAFETY 2 - Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes
• PATIENT SAFETY 3 - Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk
• PATIENT SAFETY 4 - Report potential or actual patient safety concerns, medical errors and/or near misses in a timely manner
• PATIENT SAFETY 5 - Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may "not seem right"

Qualifications

Education

Essential

• Master's Degree

Nonessential

• Master's Degree

Education specialization

Essential

• Related Discipline (BSN required if not MSN)

Nonessential

• MSN or DNP

Experience

Essential

Experience with Interqual and/or MCG Criteria 4 years directly related experience

Nonessential

Bilingual English/Keres, Tewa, Tiwa, Towa, Zuni, or Navajo

Credentials

Essential

• RN in NM or as allowed by reciprocal agreement by NM
• CPR for Healthcare/BLS Prov or Prof Rescuers w/in 30 days

Physical Conditions

Light Work: Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. May require walking or standing to a significant degree or requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or may require working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of materials is negligible.

Working conditions

• Med Haz: Mod exposure to chemicals/dangerous equip/materials
• Subject to an annual contract and performance appraisal
• Tuberculosis testing is completed upon hire and additionally as required

Relocation Assistance Available