Nurse Manager, Utilization Review (Day Shift)

Wellstar Health System; North Augusta (SC); On-site; USD 90,000 - 120,000; Full time

Job summary

Wellstar Health System seeks a senior leader to direct the Utilization Management program, driving standard of care, evidence-based guidelines and CMS compliance while coordinating with physicians and hospital departments.

The role focuses on program leadership, financial performance, staff engagement and outcomes, with responsibilities from admission through discharge across the continuum to optimize patient care and throughput.

Responsibilities

• Assumes responsibility for ongoing program coordination across the continuum from admission through discharge along with all associated follow-up.
• Maintains competency in criteria review guidelines. Insures Utilization Review competencies are completed annually.
• Analyzes, interprets and makes recommendations based on Utilization Review Reports, productivity data and financial measures.
• Serves as a liaison between clinical departments by analyzing individual dept. performance about established goals.
• Ensures compliance with CMS/commercial payor standards to maintain contract compliance and participates in JOC Meetings.
• Promotes a positive environment to patients, families, staff and the community.
• Responds to inquiries and complaints effectively and in a timely manner and promotes a positive, professional image serving as a liaison between staff, physicians, and administration.
• Demonstrates commitment to teamwork through positive interactions and feedback to/from subordinates, physicians, peers and other customers.
• Accepts responsibility for employee morale and team performance toward goal achievement. Develops measurable, team goals, monitors progress and keeps staff abreast of progress toward achievement.
• Utilizes department metrics and develops plans to direct departmental practice performance initiatives, staff satisfaction initiatives and improvements in physician relations and overall customer service.
• Represents WellStar by exhibiting values and credo.
• Continually assesses current trends/clinical/technological advances in best practice and takes appropriate action to improve outcomes and cost-effective care.
• Reviews and updates department/program specific standards/policies/procedures as needed to assure compliance with established standards, standardization efforts and current practice.
• Oversees the daily operation of the program and, in collaboration with physicians and senior leadership.
• Assess, provides for the delivery of and evaluates quality of services delivered within the program.
• Insures that all staff collaborates with Discharge Planners to enable the system to deliver services more cost effectively in the most appropriate setting to meet patient needs and communicates these needs with payers.
• Serves as an expert for payer requirements and communications to hospital staff/personnel and other health care professionals within the organization and community.
• Demonstrates, via role modeling and consultation, advanced knowledge and practice in the assessment, diagnosis, treatment and evaluation of human responses to actual and/or potential health problems.
• Consults with healthcare providers, ancillary services, patients and significant others to assess and identify individual patient care needs.

Job description

Wellstar Health System seeks a senior leader to direct the Utilization Management program, driving standard of care, evidence-based guidelines and CMS compliance while coordinating with physicians and hospital departments.

The role focuses on program leadership, financial performance, staff engagement and outcomes, with responsibilities from admission through discharge across the continuum to optimize patient care and throughput.