Manager Care Management - RN (Full Time, Days)

At Our Lady of Lourdes we offer you much more than just a job in the healthcare industry. We offer career opportunities for people who have a calling to share their gifts and talents as part of our healing ministry. As a Catholic hospital we are here to create a spirit of healing - and we invite you to join our team today if you would like to be part of that spirit. In addition to competitive salaries and generous benefits we offer you something special - the chance to do Gods work by helping to serve people in need throughout our community every day.

Job Summary: The Manager Care Management who reports to the Dir Care Management directs and oversees the utilization review process. This position maintains operational oversight for one or more areas with 24-hour accountability.

1. Evaluation and Analysis

• Contributes to the cost effectiveness/efficiency awareness of benefit system and cost benefit analysis. Demonstrates the ability to maximize financial outcomes associated with utilization of resources delays and denials medical necessity and level of care.
• Oversee and evaluate the denial and appeal process with external payer certifications.
• Coordinates and integrates quality review activities pertaining to access/medical necessity/level of care resource utilization system management analysis and evaluation in an effort to enhance operating efficiencies.
• Analyzes data prepares variance reports and monitors departmental/organizational records in order to ensure prudent resource and utilization management.
• The evaluation of the treatment plan for over/under utilization of services as they relate to cost effective delivery to facilitate appropriate reimbursement through third party payor contract.
• Evaluate the use of predictive care maps InterQual criteria Milliman Optimal Recovery Guidelines and evidence based best practice guidelines to facilitate the patient plan of care and clinical performance of Medical Staff to report potential quality and liability issues as identified.

2. Partnerships and Collaboration

• Performs the effective utilization review techniques to work with physicians third party payors and federal and local agencies to prevent denials or payments delays.
• Acts as a resource for unit personnel in the resolution of utilization and resource management problems and expediently communicates identified problems to appropriate personnel in an effort to enhance departmental operating efficiency.
• Collaborates with all members of the interdisciplinary healthcare team to ensure the optimization of reimbursement and cost-effective quality care. Plays a key role in the determination of medical necessity and/or level of care to aid in the discharge planning process for the timeliness of referrals and alternate levels of care.
• Assists in recommending developing and coordinating departmental policies and procedures and reviews those procedures in an effort to promote departmental efficiency and provide high quality health care services.
• Oversees and evaluates access coordination to determine appropriate level of care and medical necessity upon admission.
• Works closely with physicians and service line coordinators to refine processes and provide educational opportunities to medical staff to enhance utilization management.
• Works closely with physicians and service line coordinators to refine processes and provide educational opportunities to medical staff to enhance utilization management.
• Collaborates and communicates with the Utilization Managment Physician Advisor group to facilitate processes review reports for variances and establish and carry out UM plan.
• Maintains relationships with payors to facilitate communication regarding processes to ensure timeliness of authorizations and reimbursements.

3. Quality

• Evaluates the effectiveness and quality of necessary medical services medical necessity criteria and appropriateness of the level of care and alternate levels of care.
• Strives to promote the efficiency of his/her own performance by remaining current with the latest trends in field of expertise through participation in job relevant seminars and workshops attendance at professional conferences and affiliations with national and state professional organizations.
• Evaluate and analyze Departmental/Organizational performance utilizing industry and regulatory tools and benchmarks (i.e. PEPPER report) to assure efficiency and identify opportunities for improvement.

4. Other duties

• Other duties as assigned or requested.

Experience

Five years of experience in Case Management Utilization Review or a relevant leadership role.

Education

Bachelors degree

Licensure

Current and unrestricted Louisiana State License as RN