Manager Utilization Care Management

M-F 8am -430pm; occ holidays and weekends

Essential Functions

• Manages the Utilization Management development; monitors and maintains department specific goals and objectives ensuring alignment with system strategy, vision, mission, and values.
• Monitors the effectiveness/outcomes of the UM program by identifying and applying appropriate metrics; evaluating the data; reporting results to various audiences; and designing and implementing process improvement projects as needed.
• Leads and/or actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff.
• Maintains current and accurate knowledge of commercial and government payers and regulatory bodies related to UM activities.
• Ensures the UM program maintains documented, up-to-date policies and procedures and UM key processes have valid outcome measures monitored for compliance and improvement.
• Provides leadership, mentoring, and coaching to direct reports.
• Promotes effective communication and collaboration among members of the Care Management team; Physician Advisor(s); Hospital Billing; Coding; Corporate Compliance; IAS (Information Analytics Services); and other disciplines as appropriate.
• Facilitation, participation, and oversight of the following:
  • Annual updates of Utilization Review Screening Tools (i.e., InterQual/Milliman Care Guidelines) and Interrater Reliability in collaboration with IAS
  • Provides ongoing education and competencies to utilization review nurses, senior utilization review nurses, and other colleagues as desired
  • Participation in UM Committee and UM activities
• Serves as a clinical leader and system resource UM expert
• Ensures departmental compliance with regulatory standards are met and maintained.

Work requires walking, standing, lifting, reaching, bending, and stooping. Must lift a minimum of thirty-five pounds. Ability to travel/drive between various locations is required for this position. Requires frequent verbal and written communication in English. Must have intact sense of sight and hearing, finger dexterity, critical thinking, and ability to concentrate. Must be ableto respond quickly to changes in assignments. Occasional intermittent noise and exposure to conditions such as dust, fumes, and chemicals.

Master's degree required. Current RN license or temporary license as a Registered Nurse Practitioner in the state in which you work and reside or if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, current RN license or temporary license as a Registered Nurse Practitioner required in the state where the RN works. Two years of related nursing experience required; five years preferred. Experience includes but not limited to case management/discharge planning/utilization management/denial management/medical necessity review in one of the following settings: acute care, home care, long term care, physician office, or insurance plan. Appropriate Professional certification required within 3 years of hire per Clinical Care Management Certification Guidelines.

Clinical competence and critical thinking in disease management and case management principles. Must possess excellent interpersonal communication and negotiation skills, problem-solving skills, strong organizational and time management skills, and the ability to work independently and as a member of the care team.

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:

Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.