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Houston Methodist · 1 day ago

Centralized Utilization Review Manager

Katy, TX

Full-time

Onsite

Senior Level

5+ years exp

Houston Methodist is a leading healthcare provider, and they are seeking a Centralized Utilization Review Manager. This role is responsible for overseeing the operations of the Utilization Review department, ensuring compliance and efficiency in utilization management practices while collaborating with various stakeholders to optimize healthcare delivery.

Health CareMedical

Growth Opportunities

Responsibilities

Managing the daily work activities of the work unit/department staff, ensuring quality, productivity, functional excellence and efficiency while assisting management in accomplishing strategic and operational objectives

Providing guidance to staff and is responsible for staffing, budget compliance, contributing to staffing decisions such as hiring and terminating employment, coaching and counseling employees on work-related performance, and assisting in the development and implementation of policies and procedures to ensure a safe and effective work environment

Implementing training, monitoring and operations initiatives that secure compliance with ethical and legal business practices and accreditation/regulatory/government regulations

Performing management responsibilities of selection, scheduling, supervision, retention, and evaluation of employees in the department

Providing fair and consistent leadership and communication to maintain a competent and engaged employee group by conducting regular department meetings to review policies and procedures and operational matters, rounding on all employees, completing performance appraisals, conducting new hire feedback sessions, coaching/corrective counseling, and providing recognition/commendations to achieve desired outcomes

Facilitating and promoting effective team dynamics and teambuilding strategies within and between departments; participating and/or leading and facilitating department process improvements as needed

Meeting or exceeding threshold goal for department and/or system metrics on employee engagement indicators

Providing leadership to ensure operational effectiveness and efficiency of admission, concurrent and retrospective utilization management and medical claims functions to meet and exceed service-level goals and contract requirements

Serving as a liaison to physicians, case management, payers and other stakeholders

Responding to and resolving operational concerns related to utilization review processes

Maintaining ongoing interactions with physicians and staff on how to improve documentation to support medical necessity, and denials prevention

Partnering with physician advisors to support appeals, payer communications, and medical necessity reviews

Planning and organizing day-to-day department operations, schedule and activities

Setting priorities and functional standards, giving direction to staff as necessary to ensure the best possible delivery of service and high customer/patient satisfaction

Driving department service standards and activities to impact department and/or system score for patient/customer-based satisfaction, through role modeling and fostering accountability

Making and executing decisions within delegated authority

Overseeing work queue management to ensure performance targets and service-level agreements are met

Supporting maximization of UR system utilization, including length of stay (LOS), readmissions, and other KPIs as set by the organization

Ensuring a safe and effective working environment; monitoring and/or revising the department safety plan and/or any specific accreditation/regulatory required safety guidelines, including infection control principles

Employing a proactive approach in the optimization of safe outcomes by monitoring and improving the department workflow, using peer-to-peer accountability, reporting accidents, near misses, and/or adverse events immediately per department protocol and identifying solutions via collaboration

Monitoring self and employee compliance with policies, procedures, and System HR Standards of Practice and performs associated actions upon non-compliance

Generating reports to identify trends and opportunities for process improvement

Assisting in the development of department budget and ensuring that the department operates in a cost-effective manner

Managing/auditing department expenses within approved budget parameters, ensuring that the department meets the budgeted/flex revenue and/or expense targets on a monthly and annual basis

Identifying and implementing innovative solutions for practice or workflow changes to improve department operations or other department-specific measures by leading unit projects and/or other department/system directed/shared governance activities

Qualification

Registered Nurse LicensureCase Management CertificationInpatient Case ManagementAnalytical SkillsElectronic Medical RecordsLeadership SkillsCommunication SkillsInterpersonal SkillsTime ManagementFlexibilityCollaboration Skills

Required

Bachelor's degree or higher from an accredited school of Nursing

Five years' experience in inpatient case management, social work or utilization management or in the managed care/payer environment, of which one year must have been in a people management role in healthcare; for HM candidates, four years' experience in case management or social work, which includes HM performance that demonstrates progressive leadership abilities

RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)

Magnet ANCC-recognized Case Management Certification: ACHPN-HPCC or ACM-NBCM or CCM-CCMC or CDCES-CBDCE or CHPN-HPCC or CMC-NACCM or CMCN-ABMCN or CMGT-BC-ANCC or COHN-ABOHN or COHN/CM-ABOHN or CPHRM-AHA-CC or RN-BC-ANCC

Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations

Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security

Ability to effectively communicate through a variety of channels with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles; engages the recipient(s) and helps them understand and retain the message

Demonstrates the ability to interact with others in a way that gives them confidence in one's intentions and those of the organization

Ability to use appropriate interpersonal styles and techniques to gain acceptance of ideas or plans; modifying one's own behavior to accommodate tasks, situations and individuals involved

Demonstrates leadership qualities and critical thinking through self-direction initiative and effective interpersonal skills and oral/written communication skills

Ability to identify and understand issues, problems and opportunities, comparing data from different sources to draw conclusions; using effective approaches for choosing a course of action or developing appropriate solutions; taking action that is consistent with available facts, constraints and probable consequences

Ability to work effectively in a fast paced environment

Demonstrates flexibility and adaptability in the workplace

Excellent analytical skills

Advanced negotiation and mediation skills

Advanced time management and prioritization skills

Expert collaboration skills

Advanced electronic medical record skills and data reporting skills

MCG certification within one year of hire/transfer