Job Summary The Manager for Utilization Management (UM) Program is responsible for the continued development and implementation of the UM Program. The manager is responsible for adhering to operational policies and procedures and fostering a creative and innovative environment to assist in meeting network utilization management strategic initiatives. Serves as a resource to the provider practices, payors, and medical staffs. Collaborates with the Inpatient Care Management, Hospitalists, and other circle of care team members during a patient admission. Supports and contributes to the development and delivery of all UM educational programs.
Manages all UM operations. This role establishes, and reviews staff productivity, reduction in readmission rates, shortened length of stay, quality audits on work processes, outcome monitoring, resource allocations and adjustments when variances occur, coaching and training, shortened observation stays, in acute and post-acute settings. Responsible for quality review oversight of team performance. Addresses employee problems and administers appropriate disciplinary action. Ensures the UM role is adherent to the program plan to include scope, achieving goals, roles & responsibilities, measurable objectives, issues, and risk assessments. Ensures UM programs are efficiently running.
Monitor consistent entry of program metrics, outcomes monitoring, and reports (especially in the area of prior authorization timelines). Designs program quality monitoring reports and tracks results. Utilizes a variety of reporting tools with multiple data sources to include predictive analytic reports. Monitors daily, weekly, and monthly UM report and YTD readmission and referral data. Identifies trends associated with denials, Out of Network services, formulary exceptions, readmissions, high risk patients and preferred provider referral patterns.
Oversee the staff and ensure adequate staffing levels, inclusive of hiring/onboarding, evaluating, managing performance, coaching and developing employees ensuring employee productivity, quality of work, and alignment of goals with our mission, vision, and values. Ensure compliance with all policies, financial stewardship by being accountable for the financial integrity around development and maintenance of department budget.
Collaborates with PPLs, IT, and other staff in the program design.
Develops, arranges and documents educational programs. Performs community outreach with organization preferred providers. Builds a repository of community resource tools.
Keeps current on HIPAA, CMS, Federal, State, and Local regulatory requirements, new project management strategies and techniques. Maintains regulatory surveillance on intra-rater reliability testing annually. Adheres to all medical management regulations and timeframes for payors and members.
Performs other duties as assigned.
Internal Number: 2018-10893
Let’s transform healthcare together.
Every day, we bring patients convenient, coordinated access to healthcare while providing meaningful service to our community.
Join us and you will:
Develop professionally and achieve your career goals
Enrich your life with a focus on wellness
Enjoy a compassionate, caring culture with outreach to our local communities
Support the well-being of you and your family with a diverse portfolio of benefits
Welcome to HonorHealth.
We are a non-profit, local healthcare organization known for community service and outstanding medical quality. Our organization encompasses five acute care hospitals with approximately 10,500 employees and 3,100 volunteers, urgent care centers, clinical research, medical education, an inpatient rehabilitation hospital, an Accountable Care Organization, two foundations, and extensive community services.