Inpatient Utilization Management Clinical Supervisor

The Inpatient UM Clinical Supervisor is responsible for the daily supervision and operations of the Inpatient Utilization Management clinical team. Assigns work, ensures compliance with policies and procedures and is the first point of contact for complex issues to ensure cost effective utilization management of inpatient admissions. In collaboration with the UM Clinical Trainer/QA, trains newly hired staff and ensures that ongoing training needs of incumbents are met. Under the direction of the Manager of Clinical UM, uses available data to prioritize inpatient reviews including admission reviews, level of care reviews and continued stay reviews in acute and post-acute inpatient settings. Works closely with, and may share specific business goals with other clinical and non-clinical supervisor within UM to ensure and support integrated UM processes.

Key Functions/Responsibilities:
– Monitors and evaluates the quality, timeliness, and accuracy of inpatient UM reviews and discharge planning.
– Under the guidance of the UM Director and Managers, employs recommended techniques to foster team work and staff development.
– Uses subject matter expertise as well as knowledge of the interconnection between UM, claims, and regulatory requirements to respond to complex and/or escalated inquiries.
– Utilizes critical thinking skills to identify process issues and problems, and recommend and/or implement solutions.
– Under the direction of the UM managers, develops and uses metrics and management reports to monitor staff productivity, efficiency, and quality.
– May identify workflow and systems improvements to enhance UM’s ability to monitor, document, and improve key department performance indicators.
– Ensures collaboration and integration with behavioral health care management, medical care management and social care management to ensure seamless transitions.
– Collaborates with the Prior Authorization team and the care management team(s).
– Participates in staff hiring, work allocation, training, performance management, including required documentation, as well as other supervisory functions under the guidance of the Manager of Clinical UM.
– Assists with and participates in the planning, development, and implementation of department specific and cross functional projects.
– Participates in maintaining accurate, consistent, updated department policies, procedures and workflows and related training materials.
– In collaboration with the UM Clinical Trainer, is responsible for comprehensive orientation and ongoing training.
– Uses the results of routine audits to monitor compliance with department standards and goals.
– Provides high level of service and satisfaction to internal and external customers.
– Responds to issues and concerns raised by staff and escalates to management as appropriate.
– Other functions as required to support departmental activities.

Qualifications:

Education:
– Bachelor’s degree in Nursing or Associate’s degree with relevant work experience.
– Master’s degree in Nursing, related clinical field or Health Care Administration is preferred.
– CCM or Managed Care Certification preferred.

Experience:
– One year of prior supervisory experience.
– Two or more years in a managed care organization.
– Three years related RN experience in an acute care facility or health insurance environment.

Experience Preferred/Desirable:
– Experience with inpatient utilization management strongly preferred.
– Experience with CCMS and/or Jiva, or other utilization management system.
– Experience with InterQual or other nationally recognized medical necessity criteria.
– Experience with Medicaid/Medicare recipients and community services.

Required Licensure, Certification or Conditions of Employment:
– Active unrestricted state licensure as a Registered Nurse in the Commonwealth of Massachusetts

Competencies, Skills, and Attributes:
– Demonstrated ability to lead a team.
– Strong oral and written communication skills; ability to interact within all levels of the organization.
– Demonstrated comfort with ambiguity and change.
– Demonstrated ability to create positive energy with individuals and groups.
– Demonstrated ability to take action in solving problems while exhibiting sound judgement.
– Strong organizational and time management skills.
– Ability to work in a fast paced environment and multi-task.
– A strong working knowledge of Microsoft Office applications.
– Strong analytical and problem-solving skills.
– Knowledge of analytics, metrics, and the ability to interpret data.
– Demonstrated ability to successfully plan, organize and manage projects.
– Detail oriented, excellent proof reading and editing skills.
– Knowledge of process improvement techniques.

Working Conditions and Physical Effort:
– Travel to regional offices is required.

*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

Position Description »