The Supervisor of Case Management and Utilization Review works with the Director of Case Management and Utilization Review to assist with managing the Case Management duties and Utilization Review functions. Reports to the Director of Case Management and Utilization Review and CEO. Supervises the Utilization Review Coordinators, Case Managers, clerical staff, Discharge Planners, and other assigned staff. This position has frequent contacts with physicians, patients, department heads, senior management, nursing staff, social services, and state and federal agencies. Responsible for implementing and supervising the day-to-day operation of the Case Management and Utilization Management Programs of the hospital. The Supervisor in conjunction with the Director is accountable for overall program development, implantation and coordination, in accordance with organizational directive, protocols, department policies and procedures management, as well as adhering to the organizational Mission, Vision and Values. Manages activities necessary to ensure appropriate utilization of the hospital and its resources while maintaining optimal achievable standards of patient care. Maintains the strictest confidentiality of all patient information.
Responsibilities• Assists with designing and maintains an ongoing Utilization Review Program to monitor and evaluate the quality and appropriateness of patient care.
• Assures that the department follows the written plan for the Utilization Review Program and Discharge Planning Policy and that these plans are current.
• Serves as chairperson to identify problems in the Utilization Review Program, and makes recommendations to the Director to assure that department heads follow through to correct these problems.
• Reviews the Utilization Review program and makes recommendations to the Director on how to improve the quality of patient care.
• Oversees and maintains a program for patient record review and assure that these records are complete, and proper codes recorded to justify the admission length of stay, the appropriateness and the cast effectiveness of care, and the optimization of re-imbursement.
• Guides staff with in-house denials for extended length of stays
• Serves on various hospital committees as required
• Keeps abreast of current Utilization Review standards and regulations
• Interviews, selects, evaluates personal or recommend such action as necessary.
• Responsible for assuring and ongoing Utilization Review Program designed to objectively and systematically monitor and evaluate the appropriateness of patient care, purse opportunities to improve patient care, and resolve and identify problems
• Responsible for monitoring and evaluating patient care information collected to evaluate the activities involving admissions and continued stay reviews to detect any problems, trends, etc., in utilization of hospital facilities, maximize reimbursement and assure compliance with federal and state regulations and accrediting agencies.
• Responsible for the supervision of the Utilization Review and Case Management Department.
• Coordinates and manages the Case Management Department and works with staff and leaders to accomplish departmental and organization objectives.
• Guides and directs the case managers and other leaders, including the medical staff, to develop, monitor and trend outcomes related to clinical/critical pathways.
• Stays abreast of developments in the case management field and provides ongoing education to the leaders and staff within the facility.
• Oversees the case management function and serves as a liaison between the case managers and hospital and medical staff. Manages and leads the Case Management, Social Service, and Utilization Management staff to integrate their activities to facilitate a smooth and non-duplicative process.
• Monitors length of stay on a concurrent, weekly, and monthly basis. Ensures that length of stay is appropriate based on medical necessity. Works with medical staff, hospital staff and others to overcome barriers to discharge.
• Maintains knowledge of applicable DNV standards and other regulatory agency requirements and works with leaders within the organization to maintain ongoing compliance.
• Ability to develop and implement PI activities and ensure delivery of customer service
Education
Registered nurse (licensed in state of employment) from an accredited School of Nursing. Bachelor Degree in nursing and Certified Case Manager preferred.
OR
Completion of two (2) years accredited Records Technician Program with two (2) years experience or completion of an accredited program and current credentialing in a health related field.
Minimum Work Experience
Minimum of two (2) years experience in a managerial position in a clinical setting preferred.
Required Skills, Knowledge, and Abilities
Demonstrated ability to analyze, synthesize, report and manage patient care information typically obtained through previous experience in utilization review or case management.
Strong Professional, organizational, and interpersonal skills required for effective and creative leadership in working with all levels of the Organization including physicians, committees, senior management, trustees, patients and their families.
Ability to lead, support and build on current efforts of various groups working within the department’s scope of work.
Ability to extensively communicate effectively with outside agencies, third-party payors and regulators.
Function independently within the broad scope of department and organization-wide policies, practices and common goals.
In depth knowledge of InterQual Criteria Sets