Responsible for planning, coordinating and supervising assigned department(s)/area(s) to ensure an efficient and cost-effective area of responsibility in accordance with established corporate and departmental policies and procedures.
- Supervise and promote the professional development of assigned staff through selection, development, and exploration of more effective methods of managing projects and time. Research (internally and externally), initiate, and plan strategic changes in assigned department(s)/area(s) to optimize technologies and personnel.
- Recommend and assist in acquisition of technology and other tools or equipment and resources to optimize departmental performance and output.
- Prioritize and assign work to employees and initiate corrective measures to resolve problems, including scheduling or adjusting overtime requirements as necessary.
- Interface with diverse levels of internal and external personnel to develop and maintain effective rapport and to resolve issues and inquiries.
- Administer and adhere to Corporate and departmental policies, practices, and procedures. Prepare reports, manpower needs, inventories, statistical analyses, trends, etc and ability to analyze data to identify issues and opportunities.
- Conduct member home visits for small number of high risk members.
- Support non-nursing staff with clinical issues.
- Review operational data on assessment triggers and goals selected in care plans as well as goal completion rates.
- Consult and collaborate with Medical Consultants, Medical Directors, Professional Team and Health Care Providers to develop treatment plans and goals on an as needed basis
Departmental Preferences
- Minimum of 3 years of utilization management or utilization review experience in an acute care, health plan, or managed care setting preferred.
- Demonstrated proficiency in the application and interpretation of InterQual Criteria, including Adult Acute Care subsets, to support medical necessity and level of care determinations.
- Strong knowledge of Centers for Medicare & Medicaid Services (CMS) regulations, coverage requirements, and compliance standards related to utilization management.
- Working knowledge of National Committee for Quality Assurance (NCQA) Utilization Management standards, accreditation requirements, and quality improvement processes.
- Experience leading teams, facilitating collaborative problem-solving, and driving departmental performance outcomes.
- Excellent critical thinking, clinical judgment, and decision-making skills related to utilization management.
- Strong written and verbal communication skills with the ability to effectively interact with physicians, interdisciplinary teams, leadership, and internal and external stakeholders.
- Experience monitoring quality metrics, regulatory compliance, and department performance indicators.
- Ability to build a culture of accountability, engagement, and continuous improvement.
- Demonstrated success in staff coaching, conflict resolution, and change management.
- Strong organizational skills with the ability to prioritize multiple competing demands while meeting regulatory and operational deadlines.
- Commitment to delivering high-quality, patient-centered, and compliant utilization management services.
“Qualifications”
- Associate’s Degree in Nursing or RN Diploma required. Bachelor’s Degree preferred.
- Three (3) to six (6) years clinical experience and two (2) years supervisory experience.
- Strong organizational, planning, analytical and communication skills.
- Excellent interpersonal skills necessary to interact with all levels of personnel.
- Working knowledge of PC applications and/or mainframe systems preferred.
- Daily travel to assigned on site facility where applicable. Proof of auto liability coverage for nurses on site where applicable.
- Valid current Michigan driver’s license and personal means of reliable transportation for nurses on site as applicable.
- Other related skills and/or abilities may be required to perform this job.
CERTIFICATES, LICENSES, REGISTRATIONS
- Registered Nurse with current unrestricted state of Michigan license required.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.