Manager Utilization Care Management

Advocate Health Care; Charlotte (NC); On-site; USD 65,000 - 98,000; Full time

Job summary

Advocate Health Care, based in Charlotte, NC, is seeking a strong Utilization Management leader for a full-time role in Case Management. You will guide the UM program, monitor outcomes, and coordinate with multiple departments to drive policy, process improvement, and compliance.

This position emphasizes leadership, teaching, and collaboration with physicians, billing, and analytics teams. Required are a Master's in nursing with RN/NP licensure and several years of relevant experience, including

Qualifications

• Master's degree required; RN license or NP license in state of work; 2 years nursing-related experience required; 5 years preferred.
• Experience in case management/discharge planning/utilization management/denial management/medical necessity review in acute care, home care, long-term care, physician office, or insurance plan.

Responsibilities

• Lead Utilization Management development and monitor department goals.
• Provide leadership, mentoring, and coaching to UR staff.
• Ensure compliance with regulatory standards and maintain up-to-date policies.

Skills

Utilization management

Process improvement

Leadership

Interdisciplinary collaboration

Education

Master's degree

Tools

InterQual/Milliman

Job description

Position Details

Department: 11200 Atrium Health Union - Case Management Status: Full time Benefits Eligible: Yes Hours Per Week: 40 Schedule Details/Additional Information: M-F 8am -430pm; occ holidays and weekends Pay Range: $47.50 - $71.25

Essential Functions

Manages the Utilization Management development; monitors and maintains department specific goals and objectives ensuring alignment with system strategy, vision, mission, and values. Monitors the effectiveness/outcomes of the UM program by identifying and applying appropriate metrics; evaluating the data; reporting results to various audiences; and designing and implementing process improvement projects as needed. Leads and/or actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff. Maintains current and accurate knowledge of commercial and government payers and regulatory bodies related to UM activities. Ensures the UM program maintains documented, up-to-date policies and procedures and UM key processes have valid outcome measures monitored for compliance and improvement. Provides leadership, mentoring, and coaching to direct reports. Promotes effective communication and collaboration among members of the Care Management team; Physician Advisor(s); Hospital Billing; Coding; Corporate Compliance; IAS (Information Analytics Services); and other disciplines as appropriate. Facilitation, participation, and oversight of the following: Annual updates of Utilization Review Screening Tools (i.e., InterQual/Milliman Care Guidelines) and Interrater Reliability in collaboration with IAS Provides ongoing education and competencies to utilization review nurses, senior utilization review nurses, and other colleagues as desired Participation in UM Committee and UM activities Serves as a clinical leader and system resource UM expert Ensures departmental compliance with regulatory standards are met and maintained.

Physical Requirements

Work requires walking, standing, lifting, reaching, bending, and stooping. Must lift a minimum of thirty-five pounds. Ability to travel/drive between various locations is required for this position. Requires frequent verbal and written communication in English. Must have intact sense of sight and hearing, finger dexterity, critical thinking, and ability to concentrate. Must be ableto respond quickly to changes in assignments. Occasional intermittent noise and exposure to conditions such as dust, fumes, and chemicals.

Education, Experience, and Certifications

Master's degree required. Current RN license or temporary license as a Registered Nurse Practitioner in the state in which you work and reside or if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, current RN license or temporary license as a Registered Nurse Practitioner required in the state where the RN works. Two years of related nursing experience required; five years preferred. Experience includes but not limited to case management/discharge planning/utilization management/denial management/medical necessity review in one of the following settings: acute care, home care, long term care, physician office, or insurance plan. Appropriate Professional certification required within 3 years of hire per Clinical Care Management Certification Guidelines. Clinical competence and critical thinking in disease management and case management principles. Must possess excellent interpersonal communication and negotiation skills, problem-solving skills, strong organizational and time management skills, and the ability to work independently and as a member of the care team.

Our Commitment to You

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including: Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance Benefits and more Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability Flexible Spending Accounts for eligible health care and dependent care expenses Family benefits such as adoption assistance and paid parental leave Defined contribution retirement plans with employer match and other financial wellness programs Educational Assistance Program Note: Eligibility for programs listed above may depend on your FTE or status (e.g., full-time, part-time, per diem, temporary, etc.); please ask a Recruiter for more information during an interview.

About Advocate Health

Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits. This is Transformation One shared purpose brought us together. Now, as one of the 10 largest not-for-profit, integrated health systems in the United States, our combined strength and stability drives us forward. Starting with You Caring for nearly 3 million people has inspired a transformation. One in which the patient’s experience guides our vision and empowers us to offer new possibilities in our communities. Reshaping Access What is access? It’s offering more sites of care than any other health system in the Midwest. But there’s a new frontier. Access is exploring the latest technologies to deliver care to patients exactly where they are and exactly when they need it Inspiring Professionals With our dynamically inclusive workforce and strong connections to the places where we live and work, we’ll touch more lives and contribute to stronger and more vibrant communities. Transforming Care We’re redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in: Cardiovascular Care Neurosciences Gynecology Oncology Pediatrics Primary Care Neurology Geriatrics Trauma Care.