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Utilization Management Supervisor - SWHR CIN - Days - Farmers Branch

Zoek Pin Dallas, TX

Competitive

Permanent (Full time)

Southwestern Health Resources is seeking to hire a Utilization Management Supervisor for our Utilization Management Department.

The location is Southwest Health Resources- 1603 LBJ Freeway Farmers Branch TX 75234

Salary range is $###### - Max $###### - based on relevant experience.

Work Schedule

  • Full Time: Day shift with some weekends and holidays required.

The UM Supervisor will plan and direct the UM Program. This position demonstrates leadership, innovative problem solving and strategic planning to create processes and programs that translate contractual agreements into operational realities. Evidence of successful program design and implementation may be seen in improved systems performance, employee and organizational effectiveness, and customer satisfaction. In conjunction with other administrative leadership, this position is responsible for participating in the creation and promotion of new product development, implementing new operational strategies for success, and ensuring successful long-term relationships with providers. The UM Supervisor is accountable for developing a clinical infrastructure that supports all products by ensuring clinical competence and staff responsiveness while exceeding the quality expectations of all accrediting and licensing bodies. The UM Supervisor is accountable for quality management of clinical products and services. The essential job duties of this position are:

  • Helps recruit, train and retain competent, qualified professional staff for UM Department • Work with physicians and their staff to design and implement processes that facilitate appropriate resource utilization without unduly interfering with quality medical practice
  • As needed, provide clinical judgment by assessing if a member's reported condition meets medical necessity criteria for treatment and determine the appropriate level and intensity of care; ensure documentation is complete and accurate in accordance with (a) eligibility and benefits (b) clinical guidelines/criteria (c) legal and regulatory requirements.
  • Be accountable for the overall quality of the clinical programs and processes in concert with the Medical Director and Director of Care Management.
  • Be responsible for compliance with the policies and procedures, the standards of accrediting bodies and the regulations of state and local governing agencies
  • Be accountable to meet or exceed the expectations set forth in all contracts entered into by the UM Department
  • Provide a consistent, collegial professional working environment that values the diversity of individuals while supporting a team management concept
  • Comply with all compliance, regulatory and process training within the specified timeline
  • Demonstrates proficiency in the use of National review criteria and appropriate levels of care across the care continuum.
  • Demonstrates a very good understanding of managed care trends, Medicare, and Medicaid regulations, reimbursement and the effect on utilization of the different methods of reimbursement
  • Fosters a spirit of teamwork in order to produce the best care possible.
  • Collaborates with internal and external entities to improve accessibility standards and quality practice standards to reduce medical costs across the service delivery system. (inpatient, emergency departments, urgent care services and practitioner office settings)
  • Maintains good rapport with physicians, hospital personnel, social services, agencies, etc. Acts as liaison for company with outside entities and regulatory agencies when required.
  • Utilizes timely and meaningful financial and utilization reports to assist providers in efforts to alter their care delivery patterns and improve member outcomes.
  • Works collaboratively with related functional departments to design a baseline quantitative analysis of Care Management Program membership. Formulates measurable program goals based on quantitative analysis.
  • Assures alignment between health management programs and any related medical practice guidelines or utilization management criteria. Ensures that medical guidelines are current and valid and communicated to providers as appropriate.
  • Ensures that Care Management Program policies and procedures meet regulatory requirements.
  • Leads, coaches and develops staff while fostering innovation to improve member outcomes.
  • Develops, trains and mentors staff members.

Qualifications

The ideal candidate will possess the following qualifications:

  • Associate's degree in nursing required.
  • Bachelor's degree nursing preferred.
  • 2 years of expereince in managed care required And
  • 3 years of Utilization management experience in an acute or post-acute provider, health plan or other care company experience required And
  • 2 years experience in direct patient care as an RN, preferred acute care (Ortho, Cardiology, Chemo/ Radiology) required And
  • Previous experience with managed care data systems and reports required.
  • RN - Registered Nurse upon hire required.
  • CCM - or equivalent URAC Recognized Case Management certification must be obtained within 18 months of employment or transfer into position required.

Skills

  • Strong analytical and organizational skills
  • Ability to apply professional standards of practice in work environment
  • Knowledge of specific regulatory, managed care requirements preferred
  • Must be proficient in various word processing, spreadsheet, graphics, and database programs including Microsoft Word, Excel, Access, PowerPoint, Outlook, etc.

Southwestern Health Resources Clinically Integrated Network (SWHR CIN) is an affiliated company of Texas Health and UT Southwestern. If hired for this position, you will become a SWHR CIN employee rather than a Texas Health or UT Southwestern employee.

Posted 9 days ago

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