Registered Nurse (RN) Manager - Utilization Review - FT/Day - Augusta

2310 AU Medical Center, Inc.; United States; On-site; USD 110,000 - 170,000; Full time

Job summary

Wellstar in Georgia seeks an accomplished leader to oversee the Utilization Management program and ensure CMS and payer compliance. You will manage staff, coordinate with physicians and hospital departments, and drive quality and throughput improvements across the continuum of care.

The role requires 3+ years of hospital-based management experience, strong regulatory knowledge, and the ability to build collaborative, cross-functional teams to improve patient outcomes and cost efficiency.

Qualifications

• Bachelor's Degree required.
• Minimum 3 years experience managing a multidisciplinary staff in case management.
• Minimum 3 years experience in a hospital environment.

Responsibilities

• Provide leadership and operational management of the Utilization Management program.
• Ensure compliance with CMS and payer requirements and utilization review standards.
• Coordinate program functions with physicians and hospital departments to optimize quality and throughput.
• Lead quality improvement initiatives and monitor program performance metrics.
• Serve on hospital committees and liaise with regulatory bodies and payers.

Skills

Leadership

Staff management

Utilization Management

Hospital environment

Education

Bachelor's Degree

Job description

Work Shift Day (United States of America)

Responsible for providing leadership and managing all processes/services within Utilization Management program; assumes responsibility for implementing standards of practice, evidenced based medical guidelines, departmental policies and procedures, and maintaining and guiding the quality of patient care delivered; assures staff and program compliance with CMS and other payer regulatory compliance and Utilization Review standards, practices and procedures policies/procedures Responsible for financial performance, human resource management and staff engagement, appropriate reporting, and coordinating program functions with physicians and other hospital departments to assure that optimal program quality outcomes and patient throughput are achieved. Creates an environment which enables the system to fulfill its mission and goals, fosters communication and collaborative practice with physicians and other departments. Participates and supports the UM Committees within the hospital and or other hospital committees to ensure program requirements are met. Utilization Review 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.

Customer/Employee Satisfaction

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.

25% Coordinates Patient Care

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. Assesses, 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.

20% Education/Outcomes Management

Develop, revise and maintain education materials. Communication with MD offices in admission process and obtaining authorizations Clinical resource for staff development. Resource for Utilization Review within continuum of care. Sustain professional competency; pursue clinical skill development and specialty certification. Facilitate case management across the pathway to assure seamless integration of care. Develop an outcome scorecard to be utilized for benchmarking program. Identify PI opportunities to achieve compliance with best practice Track, trend and analyze data. Define opportunities for improvement from data analysis.

20% Fiscal Accountability

Assists with the development and implementation of operational and capital budgets that are consistent with system-wide, facility/divisional goals and objectives. Assists with the establishment of productivity measures and facilitates program and team achievement of established goals. Maintains FTE, salary and expense budgets at or below budgeted levels, demonstrating the ability to review/analyze current/historical data relevant to budget variances. Assists with the development of collaborative approaches that promote quality, cost-effective utilization services across the continuum. 10% Liaison for Regulatory Compliance

10% Liaison for Regulatory Compliance

Coordinates with leadership on compliance and regulatory standards as well as contractual guidelines. Develops/implements professional standards for the program based upon recognized standards of care, Joint Commission and CMS standards, state/federal regulations and overall system policies and procedures. monitors staff compliance of regulatory standards. Serves on hospital and system committees as needed. Participates in identifying learning needs for Utilization Review Team, assures staff competencies on an annual basis. Makes staff aware of community outreach and educational opportunities. Represents team at local, State, and national meetings through educational offerings and through involvement in professional organizations. Demonstrates motivation for learning through independent reading, professional networking and communicates professional expertise through publications and presentations at the local, regional, and national level.

Trust/Engagement

Builds a culture of trust and engagement as reflected in the Great Place to Work Trust Index Survey at a direct report, workgroup and hospital/entity level. Holds leaders accountable for behaviors that create trust and engagement. Performs all duties and responsibilities of this position in a manner that reflects the values of WellStar. Maintains and strengthens relationships with physicians and assures their involvement in developing systems to assure the growth of the service and the cost effective delivery of quality patient care in a manner that fosters patient and employee satisfaction.

Required Minimum Experience

• Bachelor's Degree
• REQUIRED Minimum 3 years experience in the management of a multidisciplinary staff in the field of case management
• REQUIRED Minimum 3 years experience in a hospital environment required

Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more. Nationally ranked and locally recognized for our high-quality care and inclusive culture, Wellstar is one of Georgia’s largest and most integrated healthcare systems. Every day, 24,000+ of us work together to provide personalized care for patients at every age and stage of life – and our team members are the foundation of that care.

Mission, Vision & Values

At a time when the healthcare industry is changing rapidly, Wellstar remains committed to exceeding patients’ and team members’ expectations, while transforming healthcare delivery. OUR MISSION: To enhance the health and well-being of every person we serve. OUR VISION: Deliver world-class healthcare to every person, every time. OUR VALUES: We serve with compassion We pursue excellence We honor every voice Culture of Excellence

Wellstar consistently receives attention and accolades from national organizations that set the standards for world-class care. Our system-wide practice of safety principles, assessing and addressing errors and seeking feedback from our patients and customers continually earns recognition for advances in safety and quality. Featured on the FORTUNE “100 Best Companies to Work For” list and Seramount 100 Best Companies list, we not only provide top-notch care for our patients, but also foster the culture of Wellstar as a Great Place to Work.