Manager Utilization Management & Clinical Appeals

LCS Lifespan Corporate Services d/b/a Brown University Health; Rhode Island; On-site; USD 98,000 - 195,000; Full time

Job summary

Brown University Health seeks an experienced leader to head Utilization Management, guiding nurses, payor liaisons and preauthorization staff. You will shape UM policy, drive quality, and ensure efficient resource use within Rhode Island Hospital.

Requirements include RI RN licensure, a BSN (MSN preferred), and 5+ years in UM with leadership capabilities. The role is full-time, on-site, daytime hours in Providence, RI.

Qualifications

• Current Rhode Island RN license required.
• Bachelor’s degree in nursing is mandatory.
• Master’s degree in nursing or health discipline preferred.
• Knowledge of Nurse Practice Act in Rhode Island.
• Case management certification preferred.

Responsibilities

• Provide leadership for utilization management nurses, payor liaisons and preauthorization staff.
• Participate in staff interviews, selection and evaluation.
• Develop measurements for staff competencies and orientation.
• Manage budgets and resources for utilization management.
• Serve as on-call resource for UM nurses on weekends/holidays.

Skills

Leadership

Utilization management

Staff development

Interdepartmental collaboration

Education

Bachelor’s degree in nursing

Master’s degree in nursing

RN licensure 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 programsCustomer 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

As Rhode Island's largest health system and private employer, Brown University Health is the state's premier provider of health services and includes the only Level I Trauma Center for southeastern New England. Today, more than 20,000 people work at Brown University Health and bring their unique skills, experiences, and compassion to their jobs every day. Formed in 1994, Brown University Health is a not-for-profit health system based in Providence, RI comprising three teaching hospitals of The Warren Alpert Medical School of Brown University: Rhode Island Hospital and its Hasbro Children's; The Miriam Hospital; and Bradley Hospital, the nation’s first psychiatric hospital for children; Newport Hospital, Saint Anne's Hospital and Morton Hospital, community hospitals offering a broad range of health services; Gateway Healthcare, the state’s largest provider of community behavioral health care; and Brown Health Medical Group, the largest multi-specialty practice in Rhode Island.

Brown University Health is an equal opportunity employer that values diversity of cultural background, race, gender, age, religion, identity, ability, and perspectives - we are actively committed to a diverse workforce that represents the patients and community that we serve. We are invested in creating a respectful, inclusive, and equitable environment that supports the holistic well-being of our employees and their families.

Join us and help build a healthier future for our patients - and for yourself.

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