Manager Utilization Management & Clinical Appeals

Rhode Island Hospital; Rhode Island; On-site; USD 98,000 - 195,000; Full time

Job summary

Brown University Health seeks a nursing leader to direct utilization management, including preauthorization and payor liaison staff. You will supervise, mentor, and shape the UM program while aligning with Brown's patient-centered mission in Rhode Island.

Requirements include an RI RN license, a bachelor’s in nursing, and strong knowledge of utilization review criteria; master’s degree and case-management certification are preferred.

Qualifications

• Must hold RI RN license and current nursing license.
• Bachelor's degree in nursing is required; Master's preferred.
• Understanding of Nurse Practice Act and case management certification appreciated.

Responsibilities

• Lead UM nurses, payor liaisons, and preauthorization staff including orientation, education, and competency assessment.
• Participate in interviewing and staff selection; direct activities and evaluate staff to achieve goals.
• Collaborate to develop measurements for staff competency and orientation.
• Serve as a resource to UM staff; develop departmental policies and strategic plans.
• Identify institutional needs with director and medical director; set priorities.
• Develop and adhere to budgets; ensure staffing and resources to support UM standards.
• Optimize resources to meet goals; provide on-call support for UM nurses on weekends/holidays.

Skills

Leadership

Communication

Utilization review knowledge

Nursing licensure

Education

Bachelor's degree in nursing

Master's degree in nursing or health discipline

Understanding of Nurse Practice Act

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

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

Work Type: M-F 730-4PM

Work Shift

Work Shift: Day

Daily Hours

Daily Hours: 8 hours

Driving Required

Driving Required: No