Supervisor, Utilization Manager

LE101 North Mississippi Medical Center, Inc; United States; Sur place; USD 83 000 - 104 000; Plein temps

Résumé du poste

North Mississippi Health Services is seeking a RN leader to oversee Women’s Hospital Case Management within Utilization Management. The role focuses on applying interqual criteria, coordinating care, and ensuring regulatory compliance.

You will supervise staff, participate in budget planning, educate team members, and collaborate with payers and physicians to deliver high‑quality care for a diverse patient population.

Qualifications

• Bachelor’s Degree in Nursing required.
• Master’s Degree in Nursing preferred or not required.
• RN license in Mississippi.
• Strong organizational and communication skills.
• Ability to care for pediatric to geriatric populations.
• Knowledge of payer sources and regulatory requirements.

Responsabilités

• Supervises daily utilization management activities for Women’s Hospital Case Management.
• Reviews claim denials and appeals and coordinates with payers.
• Leads daily Utilization Review team meetings.
• Assists with departmental budget development and compliance.
• Coordinates staff orientation and ongoing education.
• Ensures staff maintains current licensure and competencies.

Connaissances

Organizational skills

Communication skills

Interpersonal skills

Payer knowledge

Regulatory knowledge

Leadership

Formation

Bachelor’s Degree in Nursing

Master’s Degree in Nursing

Outils

Excel

Description du poste

We believe a career is more than just a career — it's a calling. Our teammates' \"True North\" is what calls them to health care; it’s their passion. At North Mississippi Health Services, we believe in helping you leverage and connect that passion with a much greater purpose that impacts people you know and love.

Department: 10007915 Utilization Management Work Shift: Primarily Mon thru Friday with some weekend required. Variable shift.

JOB FUNCTIONS

Supervision

• Supervises and oversees the daily activities of Women’s Hospital Case Management.
• Evaluates and provides feedback regarding individual and team performance (EXCEL).
• Recommends corrective/disciplinary actions for staff within scope of responsibility.
• Ensures that staff is meeting expectations such as placing a patient in the appropriate status at admission, applying interqual criteria, etc.
• Ensures that staff is providing quality service and functional outcomes.

Utilization Management

• Reviews claim denials and appeals.
• Identifies the need for new resources if gap exist in service continuum and initiatives creative care delivery option.

Communication

• Meets daily with Utilization Review team as necessary to address any pertinent outliers.
• Attends all required departmental, facility, and payer meetings.

Reporting

• Conducts daily review of claims, applies appropriate interqual criteria for the appropriate level of care, coordinates and completes physician/payer communication.

Educations

• Coordinates and provides orientation to all new personnel within Department.
• Educates physicians and other care team member on level of care criteria and other third party payer requirements.
• Ensures staff maintains current licensures/annual review/competencies.

Budget

• Assists with departmental budget development and compliance.

Recruitment

• Partners with Managers and Employment Services to develop and implement recruitment plan/strategies.

Regulation

• Adheres to NMHS/NMMC Policies/Procedures/Guidelines.
• Complies with applicable Local/State/Federal policies/procedures/guideline/regulations/laws/statues.
• Refers all potential quality care issues to the Case Management Director daily to facilitate timely follow-up.

Knowledge Skills and Abilities

• Excellent organizational and communication (written and verbal) skills; required.
• Knowledge of various payer sources, federal/state laws/regulations, and cost containment; required.
• Excellent interpersonal skills; required.
• Demonstrates ability to care for a patient population from pediatric to geriatric; required.
• Develops and implements departmental policies and procedures.
• Coordinates, supervises, and evaluates clinical issues of Utilization Review and support personnel.
• Leads staff meetings as appropriate.
• Conducts employee disciplinary process and implements action plans when indicated.
• Coordinates daily assignments appropriately.
• Implements new strategies as mandated by NMHS to adhere to all regulatory standards.
• Must negotiate equitable solutions in the area of continuing education, time off, and coverage to assist staff intervention.
• Must have frequent contact with: payers and physicians.
• Must have excellent written and verbal communication skills.
• Must reflect a positive, caring attitude toward clients, patients, staff and the public we serve.

Physical Demands

• Standing. Constantly
• Walking. Constantly
• Sitting. Occasionally
• Lifting/Carrying. Frequently 50 lbs
• Pushing/Pulling. Frequently
• Climbing. Occasionally
• Balancing. Occasionally
• Stooping/Kneeling/Bending. Occasionally
• Reaching/Over Head Work. Occasionally
• Grasping. Frequently
• Speaking. Constantly
• Hearing. Constantly
• Repetitive Motions. Constantly
• Eye/Hand/Foot Coordinations. Frequently

Salary Range: $83,179.20-$103,979.20

Education: Bachelor’s Degree| Nursing| Required Master’s Degree| Nursing| Not Required

Certifications: Registered Nurse (MS) - MS Board of Nursing

North Mississippi Health Services is a large rural health care system with state-of-the-art facilities in Mississippi and Alabama. We have career opportunities ranging from inpatient hospital care to 70+ rural health and specialty clinics, a variety of outpatient, women’s and behavioral health services and many additional support services. Our team of over 7,000 works together every day toward our shared mission – to continuously improve the health of the people of our region.