Role Overview: This leadership position oversees all processes within the Utilization Management (UM) program, ensuring compliance with regulatory standards and delivering high-quality patient care. Responsibilities include managing staff, developing policies, monitoring program performance, and fostering collaboration with physicians and hospital departments to optimize outcomes and patient throughput.
Key Duties:
- Lead and coordinate UM activities from admission to discharge, ensuring adherence to standards and guidelines.
- Manage financial performance, human resources, and staff engagement, promoting a positive environment.
- Oversee patient care coordination, quality assurance, and implementation of best practices.
- Develop educational materials, facilitate staff development, and serve as a clinical resource for case management and utilization review.
- Ensure compliance with CMS, payer, and regulatory standards, participating in relevant committees and professional organizations.
- Analyze data for continuous improvement, identify PI opportunities, and track outcomes for benchmarking.
- Assist in budget development, monitor expenses, and promote cost-effective utilization services.
Qualifications & Skills:
- Bachelor’s or Master’s Degree in Nursing (RN certification required).
- Minimum of 3 years in hospital case management and multidisciplinary staff management.
- Strong communication, interpersonal, multitasking, and time management skills.
- Ability to handle change in a fast-paced environment and foster teamwork.