Utilization Manager Ii

3 weeks ago

San Diego, United States Sharp Healthcare Full time

[Certified Case Manager (CCM) - Commission for Case Manager Certification; Accredited Case Manager (ACM) - American Case Management Association (ACMA); Bachelor's Degree in Nursing; California Registered Nurse (RN) - CA Board of Registered Nursing; Bachelor's Degree
**Hours**:
**Shift Start Time**:
Variable
**Shift End Time**:
Variable

**AWS Hours Requirement**:
8/80 - 8 Hour Shift

**Additional Shift Information**:
**Weekend Requirements**:
As Needed

**On-Call Required**:
No

**Hourly Pay Range (Minimum - Midpoint - Maximum)**:
$65.250 - $75.720 - $86.180

The stated pay scale reflects the range as defined by the collective bargaining agreement between Sharp HealthCare and Sharp Professional Nurses Network, United Nurses Associations of California/Union of Health Care Professionals, NUHHCE, AFSME, AFL-CIO. Placement within the range is based on years of RN experience.

**What You Will Do**
As a member of the System Integrated Care Management (ICM) team the Utilization Manager (UM) II position supports utilization review functions to ensure appropriate patient status before the patient is bedded, during the episode of care through discharge with a final status reconciliation. This position ensures timely and proactive interaction with the admitting/attending physician, payer, physician advisor and other members of the interdisciplinary care team as appropriate. This position coordinates activities with Revenue Cycle while ensuring compliance with all local, state and federal regulations governing utilization review activities and/or care management. Expected outcomes include meeting or exceeding planned divisional and organizational goals while enhancing patient satisfaction through support of appropriate billings. This position requires superior critical thinking, demonstrated exceptional knowledge of evidence-based guidelines, and best-of-class service delivery as exampled by meeting support needs, technical resource and service, as well as performance and quality. This position supports the ICM model of patient-centric care. Acts as a mentor for new hires and orientees under the direction of the ICM Centralized UM Leadership team. Participates and drives departmental excellence.

**Required Qualifications**
- Bachelor's Degree in Healthcare or a related field
- 3 Years Utilization Management or case management within a hospital or payer setting.
- 3 Years acute care nursing experience.
- 2 Years recent pertinent clinical experience as defined by the CBA.
- California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED

**Preferred Qualifications**
- Bachelor's Degree in Nursing
- Experience with Milliman Care Guidelines (MCG)
- Experience and understanding of federal and state regulations governing utilization management
- Accredited Case Manager (ACM) - American Case Management Association (ACMA) -PREFERRED
- Certified Case Manager (CCM) - Commission for Case Manager Certification -PREFERRED

**Essential Functions**
- Collaboration and teamwork
Represent management (as requested) at system and site level meetings.
Perform initial and concurrent review on intent to bed or bedded patients. Works collaboratively with system emergency departments (ED), attending physicians as well as the physician advisor.
Identifies and escalates cases not meeting criteria for admission or concurrent stay. Works proactively to identify solutions when these cases are identified. Advises the physician advisor of these cases and works to mitigate denials.
Reviews hospitalized patients with the Physician Advisor and/or facility UR chairperson as requested or required by plan/group/payer.
Identifies and reports upon as appropriate any emerging variances or trends counter to the division and organizational objectives.
Maintain records and statistics as required, i.e. - bed days, discharges, re-admissions, diagnoses.
Ensures accurate and timely completion of all documentation requirements.
Coordinates transfer of 'out-of-network' patients, when indicated.
Maintain confidentiality of all patient and Utilization Management information.
Participate in ICM Care Conferences as requested.
Work collaboratively with other members of the health care team as well as the respective medical groups to facilitate the utilization management process.
Identify and refers situations needing immediate intervention to UR Manager, Physician Advisor, as appropriate.
Participate in system or site-level utilization review activities and projects as needed.
Maintain a log and report of all high risk, long stay patients and/or otherwise outlier patients.
- Communication
Facilitates information sharing and project coordination where appropriate between teams and facilities.
Develops collaborative relationships with nursing departments, payers, hospitals, and Physicians.
Consistently models behavior, service delivery, and communication in a manner so as to distinguish the Centralized UR as an ever-role model for efficiency, superior customer

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