JOB SUMMARY The Manager Utilization Review RN provides leadership, strategic oversight, and monitoring of Utilization Review (UR) staff and programs, including the delivery of care coordination in all lines of business, management of targeted populations, expediting movement of members through appropriate levels of care, the evaluation of programs, improving programs, and creating new programs. Ability to assess and improve workflow and system configuration to meet regulatory and business requirements.
ESSENTIAL FUNCTIONS OF THE ROLE
Directs the daily operations of the Care Coordination Division related to all aspects of Utilization Management, Case Management, Disease Management, to include the staff, system, supplies, budget.
Ensures that work completed meets regulatory provisions and division policy and procedures.
Coordinates across SWHP, the system and across external entities the appropriate levels of health care services and communication to provide the highest level of service to members, providers, and other entities.
Finctions as a super user within the medical management system, requiring in-depth knowledge and understanding of how the system is configured.
Assesses impact of potential configuration changes, configure the system, create documentation and track the changes to meet standard system change requirements.
Establishes and continually improve policies, procedures, resources, auditing, and training to ensure business goals are met.
Promotes continuity of high quality care, as well as efficient utilization of health care resources by working collaboratively with the interdisciplinary teams through case management and discharge planning activities for plan members to expeditiously move patients through appropriate levels of care.
Manages and direct the delivery of continuing care to all members with special emphasis on the case management of specific targeted populations and members.
KEY SUCCESS FACTORS
Expertise in discharge planning, case management, utilization review and levels of care.
Strong written and verbal communication skills exhibiting professionalism in all encounters.
Understanding of healthcare systems and health plans.
Ability to learn and assess impact of change to medical management system to meet regulatory and business requirements.
Ability to make operational decisions around how work gets done - quality and productivity standards, measurable goals for employees and project teams, etc.
Ability to use broader objectives to determine how best to use resources to meet schedules and goals.
Ability to make or approve effective hiring and termination decisions.
Ability to evaluate and recommend changes to policies, and establish procedures that affect the managed organization.
Basic business knowledge, including but not limited to: annual planning and goal setting, adherence to budgets, employee compensation, compliance and risk management.
General computer skills, including but not limited to: Microsoft Office, information security, scheduling and payroll systems, electronic medical documentation, and email.
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!