Details
Posted: 03-Jul-25
Location: Towson, Maryland
Categories:
General Nursing
Internal Number: REF41987P
Job Description
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.
- Demonstrates comprehensive understanding and expertise in all aspects of Utilization Management, knowledge of insurance coverage, and regulatory mandates.
- Acts as a resource and mentor to the Utilization Review staff.
- 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.
- Monitors daily workflow issues and addresses issues related to workflow in collaboration with the Managers/director, as necessary.
- Contributes to the performance evaluation process by providing feedback to the Managers/Director and assisting the creation of professional development plans for UR Coordinators.
- Assists with orientation of new Utilization Review Nurses, and collaborate in the planning and monitoring progress in conjunction with other staff, as necessary.
- Communicates and collaborates routinely with the physician advisor, Care Management Managers/Director, and attending physicians to resolve problems regarding acuity and level of care.
- 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.
- Actively participates in ongoing professional improvement and educational opportunities.
- Provides input into the hiring/interview process for new case manager and/or utilization management applicants.
- 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.
- Participates in multidisciplinary quality and service improvement teams.
- Performs chart reviews to ensure chart compliance metrics achieved.
- Performs other duties as assigned.
Company Description
When you come to the University of Maryland St. Joseph Medical Center, you're coming to more than simply a beautiful 37-acre, 218-bed suburban Baltimore, Maryland campus. You're embarking on a professional journey that encourages opportunities, values a team atmosphere, and makes convenience and flexibility a priority. Joining our team of healthcare professionals means you'll be contributing to a locally and nationally recognized institution. UM St. Joseph has been recognized by The Leapfrog Group as a grade 'A' hospital and by U.S. News & World Report as #3 in both the state and Baltimore Metro area, making UM St. Joseph the highest-ranking community hospital in Maryland. In addition, we've been consistently recognized as a top employer by Baltimore magazine.
Qualifications
Education and Experience
- Bachelor's Degree from an accredited School of Nursing and Current RN License in State of Maryland is required.
- 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
- Knowledge of managed care, payers, and utilization management is required.
- Highly effective verbal and written skills are required.
- Strong communication skills, self confidence and experience dealing physicians required.
- Excellent analytical and team building skills, as well as the ability to prioritize and work independently is required.
- Must possess the ability to work collaboratively with other disciplines.
- Ability to work with Hospital/Case Management related software programs required.
- 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 patient's 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.
- Takes action to correct observed risks to patient safety.
- Reports adverse events and near misses to appropriate management authority.
- Identifies possible risks in processes, procedures, devices and communicates the same to those in charge.
