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Sup Centralized Utilization Mgmt RN

1800 Parkway Center • Marietta, Georgia • Day Shift • Full Time • JR-3028

Job Summary:

The Supervisor of Centralized UM is responsible for Training, Supervision, and Coordination of Centralized UM staffing. Provides direction/assistance to all Centralized UM Staff, students and WellStar customers. The Supervisor of Centralized UM will assist with overall coordination of the department's goals, process improvements, budgets, policies and procedures. The Supervisor of Centralized UM will assist with coordination of care across the continuum during the patient's acute, chronic and long-term stages of illness for a defined patient population. This includes utilization management, transitional care planning, patient advocacy, education for the patient's family, and monitoring quality indicators to demonstrate outcomes resulting from the service provided. Collaborates with all team members to provide a comprehensive assessment the patient's plan of care, goal/outcome attainment and continued care needs. This is a Leadership Job

Core Responsibilities and Essential Functions:

Management Duties - Coordinate care with Team Leaders, Manager, Director and other Healthcare Team Leaders. - Oversee staffing – daily staffing/ evaluates daily work distribution regarding levels demands of staff. - Daily monitoring and coaching of staff productivity and denial ratios, reports for daily volume without medical reviews completed, management of Epic WQ’s, peer to peer outcomes, E.H.R use with outcomes, avoidable days documentation and reporting, and barriers impacting utilization management workflow - Supervise, coach, mentor on general practice. - Head a team of peers to participate in the interviewing process with the Directors. - Manage QA PI activities - Provides leadership in conflict resolution - Provide guidance during the orientation process ensuring that the new employee is firmly educated in UM and Social Service issues. - Assists with yearly performance evaluations - Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education. - Serves as a preceptor and/or or mentor for other professional and/or students, to ensure that there is a current and future qualified workforce.*Professional Development and Initiative Disposition Planning - Collaboration with Discharge Planner and provides resource information in an appropriate and efficient manner. - Identification and documentation of barriers for timely disposition. - Collaboration with other members of the health care team in planning care appropriate for medical needs. - Understanding of eligibility processes and criteria for both private and public, local, state and federal resources. - Response to referrals from hospital staff, physician offices, community and family to provide resource information, counseling and education to the community. - Allowance for any cultural or religious beliefs in providing service and continuity of care. - Partnership with the patient and significant others (as appropriate) using such appropriate method for setting and purpose (e.g., interdisciplinary rounds, keeping the patient and significant others updated and making the patient’s goals the focus of the plan of care.) *Exemplary Practice and Outcomes. - Participation in the development of protocols and procedures when called upon or through self-initiation in collaboration with care managers and other members of the health care team to achieve best practice outcomes (i.e. decrease in re-admission rates, avoidable days, adverse events, etc.). *Resources and Support Utilization Management - Assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. MCG). - Insurance assessments and coverage issues such as managed care, PPO, HMO, and the identification of preferred providers. - Identification of issues relating to patient class and/or appropriateness of admission and collaborates with physician/physician advisor for resolution. - Timely identification and referral for alternative level of care. - Patient/client’s ongoing plan of care and facilitates modification utilizing established screening criteria to determine level of care with documentation in the computerized UM module. - Appropriateness of managed care denials and collaborates with attending physician and managed care representative and Medical Director. - Participates and supports performance improvement inclusive of all stakeholders, research and research utilization to promote safe, quality patient care including initiating and/or leading such activities as well as, promoting an inter/intra-disciplinary process and actively supports/participates in shared governance at all levels in the system. *Teamwork and Collaboration Documentation - Ensure all records are up-to-date and legible. - Complete all Epic UR software screens. - Ensure timely and accurate documentation of clinical reviews and insurance updates as required by payor. - Identifies and provides training opportunities for existing staff. - Participates in data collection, poses relevant clinical questions to advanced evidence-based practice. Consults appropriate experts and uses appropriate resources and evidence to address practice questions. *Evidence Based Practice and Research Assessment - Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. MCG). - Assess insurance and coverage issues such as managed care, PPO, HMO, and the identification of preferred providers. - Assess insurance and coverage issues such as managed care, PPO, HMO, and the identification of preferred providers. - Identifies issues relating to patient type and/or appropriateness of admission and collaborates with physician/physician advisor for resolution.

Job Titles Reporting to this Job:


Builds a culture of trust and engagement as reflected in the Great Place to Work Trust Index Survey at a direct report, workgroup and hospital/entity level. Holds leaders accountable for behaviors that create trust and engagement. Performs all duties and responsibilities of this position in a manner that reflects the values of WellStar. Maintains and strengthens relationships with physicians and assures their involvement in developing systems to assure the growth of the service and the cost effective delivery of quality patient care in a manner that fosters patient and employee satisfaction.

Results Oriented Leadership:

Sets challenging and productive goals for team. Holds team accountable for actions while providing leadership and motivation. Provides resources and support, Uses checkpoints and data to track progress, setting up system and processes to measure results.

Collaboration and Partnership:

Required Minimum Education:

Bachelor's Degree BSN graduate from an accredited school of Nursing with a current RN license in the State of Georgia Required and Master's Degree in Public Health (MPH) Preferred or Master's Degree in Business Administration (MBA) Preferred or Master's Degree in HealthCare Administration Preferred

Required Minimum License(s) and Certification(s):

Reg Nurse (Single State) 1.00 Required RN - Multi-state Compact 1.00 Required

Additional Licenses and Certifications:

Required Minimum Experience:

Minimum 5 years Clinical Practice/Experience is required Required Minimum 3 years expereince in Case Management/Care Coordination/Utilization Management process Required

Required Minimum Skills:

Excellent organizational and professional communication skills. Knowledgeable in utilizing screening criteria in review of clinical data with respect to patients/clients’ needs for health care. Ability to effect change, performs critical analysis, promotes client/family autonomy. Ability to plan and organize effectively for the continuum of care. Independent and self-directed. Organizational and communication skills a must. Possess knowledge of community resources.

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