Manager Utilization Management & Clinical Appeals

Lifespan; Providence (RI); On-site; USD 98,000 - 195,000; Full time

Job summary

Brown University Health is seeking a Senior Utilization Management Leader to direct UM nurses, payor liaisons, and preauthorization staff. You will guide orientation, education, and competency, and help shape departmental policies and budgets to support high-value patient-centered care.

Collaboration with the director and medical director will set priorities. The role requires RI RN licensure, a BSN, and strong communication skills; a Master's or related health discipline is preferred, with case

Qualifications

• Must hold an active Rhode Island RN license.
• Bachelor’s degree in nursing is required.
• Master’s degree in nursing or another health discipline is preferred.
• Familiarity with Rhode Island Nurse Practice Act is required.
• Certification in case management is preferred.

Responsibilities

• Direct and develop utilization management nurses, payor liaisons, and preauthorization staff; oversee orientation, education, and competency assessment.
• Partner with the Director to establish staff competency measures and orientation processes.
• Develop departmental policies, plans, and budgets; align priorities with utilization management goals.
• Identify institutional needs with the director and medical director; prioritize initiatives.
• Manage resources to meet goals; serve as on-call resource for UM staff on weekends/holidays.

Skills

Leadership

Clinical nursing

Utilization management

Communication skills

Education

RN license in RI

Bachelor's degree in nursing

Master's degree in nursing or health discipline

RI Nurse Practice Act knowledge

Case management certification preferred

Job description

SUMMARY

Under the general direction of the Director Utilization Management, provides leadership for utilization management nurses, payor liaison/utilization management specialists and preauthorization staff assigned to the utilization management department. Participates in the design, development, implementation and improvement of the utilization management model at Brown University Health. Fosters patient and family centered care in accordance with the Brown University Health mission, vision and values. Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect and Excellence, as these values guide our everyday actions with patients, customers and one another. In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include: Instill Trust and Value Differences Patient and Community Focus and Collaborate In addition, our leaders will demonstrate an aptitude for: Ensure Accountability and Build Effective Teams Drive Vision and Purpose and Optimize Work Processes By applying core and leadership competencies, leaders help Brown University Health achieve its strategic goals.

RESPONSIBILITIES

• Provides for leadership of utilization management nurses, payor liaisons and other preauthorization staff including orientation, continuing education, and competency assessment. Participates in the interviewing process. Recommends selection of staff, direct activities and evaluates professional and support staff to optimize achievement of goals and objectives.
• In collaboration with the Director of Utilization Management develops measurements for evaluating staff competencies and orientation.
• Acts as a resource to utilization managers and payor liaisons and support staff. Develops departmental policies and strategic plans.
• In collaboration with the director utilization management and the medical director of utilization management identifies institutional needs and determines priorities.
• Develops, analyzes and adheres to departmental and capital and operating budgets, ensuring appropriate staffing and resources are in place to support utilization management standards of practice.
• Provides for the effective utilization of resources (people, financial, material and equipment) to meet established goals and objectives.
• Responsible to be an on-call resource to all system utilization management nurses on rotating weekend and holidays

PERFORMANCE STANDARDS

• Effective utilization of resources
• Management of continuous quality improvement
• High quality, high value patient-focused services
• Resource productivity
• Fiscal responsibility
• Development and implementation of effective quality programs
• Customer satisfaction
• Performance improvements year-to-year
• Positive feedback from peers, direct reports and staff

MINIMUM QUALIFICATIONS

• Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.

QUALIFICATIONS - EDUCATION

• Must have a current license to practice as a registered nurse in the State of Rhode Island.
• Bachelor's degree in nursing required.
• Master's degree in nursing or other health discipline preferred.
• Understands the provisions of the Nurse Practice act of the State of Rhode Island.
• Certification in case management preferred.

QUALIFICATIONS - EXPERIENCE

• Five years relevant clinical/utilization management experience with demonstrated leadership skills.
• Experience should demonstrate a high level of written and oral communication skills.
• Knowledge of utilization review criteria.
• Previous case management/utilization management leadership experience is highly desirable

SUPERVISION

• Management responsibility for up to 40 FTEs.

PAY RANGE

$97,718.40-$195,436.80

EEO STATEMENT

Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

LOCATION

Rhode Island Hospital - 593 Eddy Street Providence, Rhode Island 02903

WORK TYPE

M-F 730-4PM

WORK SHIFT

Day

DAILY HOURS

8 hours

DRIVING REQUIRED

No