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Manager, Utilization Review (RN Required)

Work Schedule/Days:  Day / Monday - Friday
Employment Type:  Full-Time
Location:  Support I 
Requisition #:  64966

 

JOB SUMMARY

Manages day-to-day operations of the Utilization Review department. Ensures effective and efficient clinical utilization review services are delivered related to precertification, denial analysis, and other revenue-related activities. Proactively supports efforts that ensure delivery of safe patient care and services and promote a safe environment at Children's Healthcare of Atlanta.

EDUCATION

  • Bachelor of Science in Nursing

CERTIFICATION SUMMARY

  • Licensure as a Registered Nurse in the single State of Georgia or Multi-State through the Enhanced Nurse Licensure Compact

  • Professsional nursing certification required upon hire or within one year of hire

EXPERIENCE*

  • Experience in management of the utilization review functions within a mid to large hospital (200+ beds)
  • Experience in people management, including hiring, training, coaching, and counseling
  • Experience in developing processes, procedures, and policies that positively impacted efficiencies

PREFERRED QUALIFICATIONS*

  • Master's degree in nursing, business, or other healthcare related field
  • Experience in change management, including leading teams during system implementations and upgrades
  • Professsional nursing certification required upon hire or within one year of hire

KNOWLEDGE SKILLS & ABILITIES*

  • Ability to use Microsoft Excel to create spreadsheets, review and sort data, and create formulas
  • Ability to use Microsoft Word to create and format written documents
  • Must be able to score 80% or higher on the Basic Windows Skill Assessment
  • Working knowledge of federal, state, and local regulatory requirements
  • Excellent written and oral communication skills
  • Able to function in a dynamic environment subject to impromptu changes in schedules and priorities

JOB RESPONSIBILITIES*

  1. Oversees day-to-day management and operations of Utilization Review.
  2. Functions as clinical resource for department and internal staff, demonstrating a thorough knowledge of all utilization review policies, procedures, and government insurance programs.
  3. Serves as resource for administrators and contracted vendors.
  4. Develops, updates, maintains, and communicates utilization review policies and procedures to ensure compliance with state and federal regulations, Joint Commission standards and criteria, and documentation requirements.
  5. Recruits, hires, orients, and continuously trains new employees to ensure success and a thorough understanding of necessary policies, processes, and procedures. 
  6. Develops staff performance expectations, metrics, and goals and holds self and staff accountable to achieving.
  7. Establishes and communicates performance and behavioral standards and follows appropriate disciplinary courses of action when counseling staff.
  8. Assists director with budget preparation and budget analysis and ensures budget adherence.
  9. Runs daily, weekly, and monthly reports to monitor and analyze performance, assess data against standards and goals, identify trends, and make adjustments as necessary.
  10. Keeps leadership, staff, and physicians informed as appropriate.
  11. Works closely with Case Management to ensure effective department collaboration.
  12. Collaborates with medical staff and all levels of hospital personnel as appropriate to ensure effective coverage and precertification requirements are met.
  13. Communicates with and educates physicians as needed regarding utilization review policies, practices, and procedures to ensure appropriate level of knowledge.
  14. Identifies and maintains relationships with other departments (e.g., Case Management, Managed Care, Patient Accounting, Patient Access) and medical staff to facilitate inpatient utilization review process and provide continuity of care.
  15. Performs other duties as necessary or assigned.
  16. Demonstrates mastery of the utilization review process with successful completion and passing of McKesson Certified Instructor Program.
  17. Responsible for all aspects of managing and leading a team including: interviewing, hiring, training, developing, directing work and processes, managing performance, recognizing, and rewarding employees.
  18. Mentor team members to encourage personal and professional growth.
  19. Encourage ongoing skill development by providing opportunities for continued education.

SYSTEM RESPONSIBILITIES*

Safety: Practices proper safety techniques in accordance with hospital and departmental policies and procedures. Responsible for the reporting of employee/patient/visitor injuries or accidents, or other safety issues to the supervisor and in the occurrence notification system.

 

Compliance: Monitors and ensures compliance with all regulatory requirements, organizational standards, and policies and procedures related to area of responsibility. Identifies potential risk areas within area of responsibility and supports problem resolution process. Maintains records of compliance activities and reports compliance activities to the Compliance Office.

 

The above statements are intended to describe the general nature and level of work performed by people assigned to this classification.  They are not intended to be an exhaustive list of all job duties performed by the personnel so classified.

PHYSICAL DEMANDS*

Ability to lift up to 15 lbs independently not to exceed 50 lbs without assistance
Bending/Stooping - Occasionally (activity or condition exists up to 1/3 of time)
Climbing - Occasionally (activity or condition exists up to 1/3 of time)
Hearing/Speaking - Effective communication with employees, supervisors/managers and staff. Effective communications with patients and visitors, as required.
Lifting - Occasionally (activity or condition exists up to 1/3 of time)
Pushing/Pulling - Occasionally (activity or condition exists up to 1/3 of time)
Sitting - Constantly (activity or condition exists 2/3 or more of time)
Standing - Occasionally (activity or condition exists up to 1/3 of time)
Walking - Occasionally (activity or condition exists up to 1/3 of time)

WORKING CONDITIONS*

Some potential for exposure to blood and body fluids

 

About Us:

Children’s Healthcare of Atlanta has been 100 percent committed to kids for more than 100 years. A not-for-profit organization, Children’s is dedicated to making kids better today and healthier tomorrow.

With 3 hospitals, 20 neighborhood locations and a total of 673 beds, Children’s is the largest healthcare provider for children in Georgia and one of the largest pediatric clinical care providers in the country. Children’s offers access to more than 60 pediatric specialties and programs and is ranked among the top children’s hospitals in the country by U.S. News & World Report.

Children’s has been recognized as a Fortune 100 Best Place to Work, a Best Place for Working Mothers, and as a top employer for diversity and millennials.  We offer a comprehensive compensation and benefit package that supports our mission, vision and values.  We are proud to offer an array of programs and services to our employees that have distinguished us as a best place to work in the country.  Connect to our mission of making kids better today and healthier tomorrow. 

Have questions about the recruitment process?  Check out What to Expect.

Address:  1575 Northeast Expressway, Bldg 1, Atlanta, GA  30329
Function:  Nursing - Nursing - Management


Nearest Major Market: Atlanta

Job Segment: Nursing, Medical, Manager, Patient Care, Pediatric, Healthcare, Management