Under the guided support ofthe Manager/Executive Director of Utilization Management, Inpatient Services, thisposition has the responsibility for the day to day operations of ClinicalServices, Utilization Management Inpatient Services for all hospital campuses.The incumbent shall plan, organize, directand evaluate people and activities for the department to maximize medicalnecessity review compliance, clinical authorizations, billing compliance andappeals. The position requires working with inpatient case management, PFS,Patient Access, HIM, external payors, Managed Care, the aligned MedicalDirectors and other identified leadership to achieve the overall strategicgoals of the department as it relates to the cost-effective utilizationmanagement processes that supports patient care while maximizing the revenuecycle rendered by providers to patients with in each inpatient hospital serviceof MemorialCare.
The incumbent is anexpert-level clinician that supervises and assists when necessary per therequirements of the Supervisor-Clinical Services Utilization ManagementInpatient Services job description and standard work for the UtilizationManagement-Inpatient Services.Inaddition, the Supervisor-Clinical Services Utilization Management InpatientServices responsibilities include input into the assessment, planning,implementing and evaluation of individuals, standard work and processes of anassigned team to ensure consistent high-quality, cost-effective patient care.The Supervisor is responsible for coaching,auditing and coordinating standard work of the assigned team.The success of the Utilization ManagementInpatient Services team is inherent in the incumbent's ability to demonstratepositive, professional communication with patients, physicians, departmentaland interdepartmental staff to optimize workflow and to facilitate problemidentification and resolution.
Principal Duties and Responsibilities:
The Supervisor-ClinicalServices Utilization Management Inpatient Services reports to the Manager ofUtilization Management, Inpatient Services for establishing, maintaining andcontinuously improving processes required to achieve the defined scopes of theclinical teams of inpatient utilization management as well as direct managementand training of the inpatient utilization management team of UtilizationManagement-Inpatient Services for all hospital campuses.
Addingto the general fiscal health of MHS entities as subject matter expert forauthorization, billing compliance and appeals processes by promoting utilizationmanagement processes that provide authorizations, billing compliance andappeals support.
Responsible for participation and guidance of the UtilizationManagement Inpatient Services department and reports Quality Managementactivities to the hospital Utilization Management Committees and the QualityCouncils.
Responsible for the supervision of operations and management of theteam assigned within the Utilization Management Inpatient Services department, includingmonitoring and reporting as required by regulation or contract.
Responsible for supervising the Clinical Service Teams ofUtilization Management Inpatient Services which may include, but not limited tothe following positions: RN Lead Case Manager, Utilization Review Assistant,Utilization Review Specialist, Utilization Review Professional, UtilizationManagement Case Management RN, and Data Coordinator.
Formalize administrative care coordination and utilizationmanagement processes, roles, team evaluations, department budget responsibilities,policy and procedures, and continuously update documents as improvements areimplemented under the guidance of the Executive Director of UtilizationManagement.