Manager Utilization Review - Utilization Resource Management

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range:

$97,947.20 - $127,982.40

Scheduled Weekly Hours:

40

Position Overview

Please note - this is not a remote position

Performs a variety of utilization review activities to promote quality, clinical and cost-effective outcomes, including evaluation of length of stay and resource consumption. Manages activities of assigned staff in the process of providing utilization review. Plans, assigns, reviews and evaluates the work of assigned staff to achieve quality patient care, to operate in a fiscally responsible manner, to achieve operational efficiency and to adhere to established policies, practices, and procedures. Identifies opportunities and takes a leadership role in departmental performance improvement activities.

MINIMUM REQUIREMENTS
Education:    Bachelor of Science in Nursing (BSN). An Associate Degree in Nursing (ADN) and additional years of experience may be considered in lieu of a BSN.
Experience:    Four years of experience in nursing, including experience in the case management field in utilization review, discharge planning, outcomes management, assessment, care planning and/or care coordination when accompanied by a BSN. Six years of experience in nursing, including experience in the case management field in utilization review, discharge planning, outcomes management, assessment, care planning and/or care coordination when accompanied by an ADN.
Other Credentials:    Registered Nurse - NJ
Knowledge and Skills:    Excellent interpersonal, communication and negotiation skills with ability to convey understanding of complex issues. Ability to interpret a variety of instructions furnished in written or oral form. Strong organizational and time management skills. Strong leadership, motivational and team building skills.
Special Training:    Analytical and data management skills.
Mental, Behavioral and Emotional Abilities:    
Usual Work Day:    8 Hours  
Reporting Relationships
Does this position formally supervise employees? Yes

If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

ESSENTIAL FUNCTIONS
Performs all daily Utilization Review Functions, includes communicates with payers, performs clinical reviews utilizing the appropriate guidelines, policies, and timelines. Identifies, develops, and implements strategies to facilitate appropriate length of stay and resource consumption.
Supervises utilization review staff to ensure that appropriate processes are followed according to CH policy and utilization guidelines.
Ensures equitable distribution of work assignment on a daily basis. Adjusts work assignments throughout shift as needed. Accepts staff call-outs and arranges alternate staffing as appropriate. Ensures that appropriate staffing level are maintained through proactive planning.
Conducts routine reviews of utilization staff work product including reviews, payer correspondence, and resource management documentation to identify opportunities to enhance compliance with documentation requirements.
Provides ongoing feedback to utilization review director regarding department performance.
Acts as liaison with the administrative staff to handle any problems that arise. Advises director when physician or patient issues require legal, ethical, or administrative interventions.
Attends system level meetings and represents utilization review services in order to promote and develop good working relationships. Participates in system wide committees as assigned, such participation should also enhance knowledge of and about UR.
Provides for effective function of department by interviewing, hiring and training new utilization management staff.
Provides for ongoing function of department by assessing educational needs and providing training and ongoing mentoring to the utilization staff.
Conducts performance appraisals, manages the reward and discipline process and addresses complaints and resolves problems within the utilization management department.
Participates in performance improvement projects
Participates in DNV and other regulatory compliance activities.
Maintains and enhances relationships with internal and external customers and peers across the system in order to achieve excellent working relationships.
Assures that established outcome measures are met and that continuous quality improvement approach is in place for all utilization review.

PHYSICAL DEMANDS AND WORK ENVIRONMENT
Frequent physical demands include: Sitting , Standing , Walking , Carry objects , Wrist position deviation , Pinching/fine motor activities , Keyboard use/repetitive motion

Occasional physical demands include: Climbing (e.g., stairs or ladders) , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Squat/kneel/crawl

Continuous physical demands include:

Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs.

Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Color Discrimination, Minimal Depth Perception, Minimal Hearing
Anticipated Occupational Exposure Risks Include the following: Bloodborne Pathogens , Chemical , Airborne Communicable Disease , Extreme Temperatures

IND123.

This position is eligible for the following benefits:

• Medical Plan

• Prescription drug coverage & In-House Employee Pharmacy

• Dental Plan

• Vision Plan

• Flexible Spending Account (FSA)

- Healthcare FSA

- Dependent Care FSA

• Retirement Savings and Investment Plan

• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance

• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance

• Disability Benefits – Long Term Disability (LTD)

• Disability Benefits – Short Term Disability (STD)

• Employee Assistance Program

• Commuter Transit

• Commuter Parking

• Supplemental Life Insurance

- Voluntary Life Spouse

- Voluntary Life Employee

- Voluntary Life Child

• Voluntary Legal Services

• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance

• Voluntary Identity Theft Insurance

• Voluntary Pet Insurance

• Paid Time-Off Program

The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. 

The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.