Utilization Nurse Reviewer

On Site *** Office Location: 5350 Spring Hill Drive, Spring Hill **

Summary Under general supervision, responsible for directing and conducting all health services managed care activities, including but not limited to Utilization Management, Case Management and Disease Management. Duties include oversight of Utilization Management and Care Management staff (clinical and non clinical) in planning, directing and coordination of daily activities to achieve the overall goals of the medical management program. Manages clinical and support staff that identify, coordinate, or provide appropriate levels of care. Accomplishes this by performing the following duties.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

Supervises the utilization management and care management staff and oversees all utilization management and case management day-to-day operational activities.

Assists senior leaders with program design and practices and writes policies and procedures that meet CMS and accreditation standards, clinical practice guidelines, chronic care improvement plans (CCIPs), job aids and protocols, and reporting quality of care issues identified during the utilization review process.

Evaluates needs and special programs for our Special Needs Program and completes annual SNP/HEDIS requirements.

Promotes performance improvement; plans for and oversees systematic measurement, monitoring, and evaluation of care and services; designing and implementing improvement activities based on findings.

Ensures staff members are conducting appropriate case and care management reviews, audits programs and implements all aspects of the Utilization Management Program as identified, in a timely manner.

Assists clinical staff with utilization decisions such as those determining if requested services are a covered benefit.

Ensures clinical staff interventions are aimed at supporting the care plan and enhancing the member's ability to comply and adapt to his/her illness.

Verifies clinical staff are consulting and collaborating with the primary care physicians and medical director regarding high risk member treatments, adverse events and cases where treatment potentially fails to meet established medical standards.

Collaborates with health plan department managers and attend interdepartmental meetings as requested.

Maintains an orientation program for new hires and provide in-service training for staff as indicated.

Participates in utilization review and quality management programs.

Summarizes and analyzes data; prepares statistical reports; implements decisions in program according to revisions in standards.

Assesses and reviews health care delivery to promote cost effective quality of care.

Manages strategic goals of the organization, federal and state law and regulations, and URAC accreditation standards.

Educates and trains the leadership, staff, and business associates as to the utilization management plan and their respective responsibilities relative to the plan.

Collects, analyzes, and maintains data on the utilization of medical services and resources.

Prepares and presents monthly utilization management and care management reports to Sr. Director, identifying potential areas for improvement.

Assists in development and/or updating of health services care management database

Reports quality of care issues identified during the utilization review process according to policy and procedure.

Devotes at least 25% of his/her time to quality management, performance improvement, activities

Directs the development and expansion of the utilization and resource management program.

Responsible for evidence-based referral management, inpatient concurrent review and care management insuring efficiency, effectiveness and compliance with regulatory standards.

Provides industry-standard utilization and cost data measured against program-wide regional and external benchmarks/goals for all areas of service managed by the department.

Completes UM delegation responsibilities

Ensures compliance with all state and federal regulations and guidelines in day-to-day activities

Attend workshops and seminar to improve knowledge.

Participate in various task force and committee projects, as requested.

Supervisory Responsibilities

Directly supervises 15 - 20 employees in the Health Services department. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Competencies

To perform the job successfully, an individual should demonstrate the following competencies :

Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Designs work flows and procedures.

Design - Demonstrates attention to detail.

Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.

Project Management - Develops project plans; Coordinates projects; Communicates changes and progress; Completes projects on time and budget; Manages project team activities.

Technical Skills - Assesses own strengths and weaknesses; Pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others.

Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Meets commitments.

Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.

Oral Communication - Speaks clearly and persuasively in positive or negative situations; Listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.

Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.

Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed.

Visionary Leadership - Displays passion and optimism; Inspires respect and trust; mobilizes others to fulfill the vision; Provides vision and inspiration to peers and subordinates.

Change Management - Develops workable implementation plans; Communicates changes effectively; Builds commitment and overcomes resistance; Prepares and supports those affected by change; Monitors transition and evaluates results.

Delegation - Delegates work assignments; Matches the responsibility to the person; Gives authority to work independently; Sets expectations and monitors delegated activities; Provides recognition for results.

Leadership - Exhibits confidence in self and others; Inspires and motivates others to perform well; effectively influences actions and opinions of others; Accepts feedback from others; Gives appropriate recognition to others.

Managing People - Includes staff in planning, decision-making, facilitating and process improvement; Takes responsibility for subordinates' activities; Makes self available to staff; Provides regular performance feedback; Develops subordinates' skills and encourages growth; Solicits and applies customer feedback (internal and external); Fosters quality focus in others; Improves processes, products and services.; Continually works to improve supervisory skills.

Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.

Business Acumen - Understands business implications of decisions; Displays orientation to profitability; Demonstrates knowledge of market and competition; Aligns work with strategic goals.

Cost Consciousness - Works within approved budget; Develops and implements cost saving measures; Contributes to profits and revenue ; Conserves organizational resources.

Diversity - Shows respect and sensitivity for cultural differences; Promotes a harassment-free environment; Builds a diverse workforce.

Ethics - Treats people with respect; Keeps commitments; inspires the trust of others; Works with integrity and ethically; Upholds organizational values.

Organizational Support - Follows policies and procedures; Supports organization's goals and values; Supports affirmative action and respects diversity.

Judgment - Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.

Motivation - Sets and achieves challenging goals; Demonstrates persistence and overcomes obstacles; Measures self against standard of excellence.

Planning/Organizing - Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources; Sets goals and objectives; Organizes or schedules other people and their tasks; Develops realistic action plans.

Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.

Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.

Quantity - Meets productivity standards; Completes work in timely manner; Strives to increase productivity; Works quickly.

Safety and Security - Observes safety and security procedures; Reports potentially unsafe conditions; Uses equipment and materials properly.

Adaptability - Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events.

Attendance/Punctuality - Is consistently at work and on time; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time.

Dependability - Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary to reach goals. Completes tasks on time or notifies appropriate person with an alternate plan.

Initiative - Seeks increased responsibilities; Asks for and offers help when needed.

Innovation - Meets challenges with resourcefulness; Generates suggestions for improving work.

Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

Bachelor's degree (B. A.) from four-year college or university; or Associate’s degree from a two year college or one to two years related experience and/or training.

Masters Degree a plus

Managed care experience required

Language Skills

Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.

Mathematical Skills

Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Computer Skills

To perform this job successfully, an individual should have expert working knowledge of Microsoft Office software, including Microsoft Excel, Access, and Word as well as MS Internet Explorer.

Certificates, Licenses, Registrations

Current, unrestricted Florida professional license, R.N.;

Continuing education requirements are met through renewal of licensure by the FL Department of Health.

CCM certification, a plus

Other Skills and Abilities

Some travel required, provider visits

Other Qualifications

At least 2-5 years previous experience in utilization and/or case management within a Managed Care and Medicare environment required.

Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to talk or hear. The employee must occasionally lift and/or move up to 10 pounds.

Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Job Type: Full-time

Pay: From $65,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Experience:

• Medical records: 1 year (Preferred)
• CTST: 1 year (Required)
• RN: 5 years (Required)
• HEALTH PLAN: 1 year (Preferred)
• Managed care: 2 years (Required)
• HEDIS: 2 years (Required)

License/Certification:

• RN License (Required)

Work Location: In person