Incumbent is responsible for: * Planning, organizing, managing and evaluating Utilization Management and Case Management teams. * Monitors achievement of program objectives and implement program changes to improve outcomes. * In collaboration with the Manager, the Supervisor prepares, administers and monitors departmental operating and capital budget and maintains budgets within allocated funds. * Participates in the development of policies and procedures of the Department. Allocates and assigns staff for proper utilization of personnel in relation to patient, service line and organizational needs. * Initiates hiring and termination decisions, and performs timely annual evaluations and coaching sessions. * Schedules and monitors assignments, and controls staffing levels to meet budgetary guidelines. * Provides counseling, training, and addresses disciplinary problems. * Maintains a supportive attitude towards department and facility goals, plans, policies, and procedures. * Promotes the role of utilization management and case management within the Health System by effective liaison with managers, directors and physician leaders. * Participates in the planning and development of educational programs for Utilization Management and Case Management staff. Coordinates and documents departmental orientation and in-service training. * Provides expertise and direction to Hospital Care Management staff for solving complex clinical and financial patient situations regarding reimbursement issues, discharge planning, utilization review, continuity of care, and systems management. * Supports culture of continuous quality improvement. Works within a team environment to manage the total function of the Hospital Care Management service. Actively participates in organizational committees. * Participates in activities of professional associations. * Promotes a positive, safe environment. * Keeps abreast of current professional standards in the health field and makes recommendations on changes in policy and programs. * In collaboration with the treatment team, attending physician, and external entities, may provide direct service care to patients. * Performs other related duties as may be requested by Administration of the Health System. KNOWLEDGE, SKILLS AND ABILITIES: * Thorough working knowledge of Medical Terminology. * Demonstrated knowledge of: * Utilization Management and Case Management principles and methodology * Knowledge of Levels of Care (Acute care, Critical Care, Acute Rehab, LTAC, SNU, Subacute, Outpatient, Home Health, Day Tx.) * Thorough working knowledge of: * Government, county, private, and workers compensation funding sources. * Eligibility criteria * Criteria for determining level of care, and familiarity with managed care (HMO, PPO, PSO, and capitation) * Federal and State regulatory requirements and URAC standards * Demonstrated ability to: * Communicate effectively with health care professionals and external case managers. * Identify obstacles to patient progress and barriers to discharge. * Problem solve with medical team to remove such barriers. * Maintain professional relationships; work effectively and collaboratively with other members of the medical team. * Actively pursue continuing education and training opportunities in Utilization Management or Case Management. * Ability to maintain knowledge regarding standards of care, case management/utilization principles and approaches, Social Services, discharge management and Spiritual Care. * Ability to maintain confidentiality regarding the medical record. * Understand insurance and payer requirements. * Demonstrate the knowledge and skills necessary to provide care based on physical, motor/sensory, psychosocial, and safety appropriate to the age. * By nature of current license for RN and department evaluation competency is demonstrated for ability to perform job duties. This position may provide direct patient care.
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