Lead Care Manager (RN), $15,000 Sign-on Bonus

General Summary

Under limited supervision assists the managers of Integrated Care Management in the supervision of the utilization management team. This includes providing guidance in regards to policies and procedures related to concurrent review denial management and contract regulations. Provides input regarding human resource functions. Provides input into performance improvement strategies.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by staff assigned to this classification. They are not to be construed as an exhaustive list of all duties.

1. Demonstrates comprehensive understanding and expertise in all aspects of Utilization Management knowledge of insurance coverage and regulatory mandates.
2. Acts as a resource and mentor to the Utilization Review staff.
3. In the absence of the Managers assists in managing the daily departmental operations with the goal of maintaining adequate staffing levels and efficient workflow including monitoring performance issues.
4. Monitors daily workflow issues and addresses issues related to workflow in collaboration with the Managers/director as necessary.
5. Contributes to the performance evaluation process by providing feedback to the Managers/Director and assisting the creation of professional development plans for UR Coordinators.
6. Assists with orientation of new Utilization Review Nurses and collaborate in the planning and monitoring progress in conjunction with other staff as necessary.
7. Communicates and collaborates routinely with the physician advisor Care Management Managers/Director and attending physicians to resolve problems regarding acuity and level of care.
8. Performs concurrent and retrospective reviews to determine medical necessity using accepted criteria based on age specific needs. Interacts with and assists third party payer reviewers to facilitate appropriate care and ensure payment of services.
9. Actively participates in ongoing professional improvement and educational opportunities.
10. Provides input into the hiring/interview process for new case manager and/or utilization management applicants.
11. Helps in collecting tabulating and analyzing data in collaboration with the case management team medical staff and hospital performance improvement initiatives. Assist in implementing strategies to correct or modify trends seen through data analysis and outcome monitoring.
12. Participates in multidisciplinary quality and service improvement teams.
13. Performs chart reviews to ensure chart compliance metrics achieved.
14. Performs other duties as assigned.

Qualifications :

Education and Experience

1. Bachelors Degree from an accredited School of Nursing and Current RN License in State of Maryland is required.
2. Three years of experience in utilization management and case management. Three years of experience in acute care preferred four years clinical healthcare experience preferred. Additional experience in home health ambulatory care and/or occupational health is preferred

Knowledge Skills and Abilities

1. Knowledge of managed care payers and utilization management is required.
2. Highly effective verbal and written skills are required.
3. Strong communication skills self confidence and experience dealing physicians required.
4. Excellent analytical and team building skills as well as the ability to prioritize and work independently is required.
5. Must possess the ability to work collaboratively with other disciplines.
6. Ability to work with Hospital/Case Management related software programs required.
7. Ability to demonstrate knowledge and skills necessary to provide care appropriate to the patient population(s) served. Ability to demonstrate knowledge of the principles of growth and development over the life span and ability to assess data reflective of the patients requirements relative to his or her population-specific and age specific needs.

Patient Safety

Ensures patient safety in the performance of job functions and through participation in hospital department or unit patient safety initiatives.

1. Takes action to correct observed risks to patient safety.
2. Reports adverse events and near misses to appropriate management authority.
3. Identifies possible risks in processes procedures devices and communicates the same to those in charge.

Additional Information :

All your information will be kept confidential according to EEO guidelines.

Compensation

• Pay Range: $41.50 - $53.18
• Other Compensation (if applicable): 
• Review the 2024-2025 UMMS Benefits Guide

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