Inpatient Managed Care Manager
- Arms Acres - Nursing Admin
- Carmel, NY, USA
- Full Time
Under administrative direction, to plan, organize, and manage the centralized utilization review program and related functions; and to perform related duties as required.
ESSENTIAL DUTIES and RESPONSIBILITIES include the following. Other duties may be assigned.
- Travels between inpatient sites to provide a supported centralized Utilization Review department.
- Supervises staff at both Conifer Park(UR) and Arms Acres(UR, Insurance Verification. and Business Office) including assigning, reviewing, and evaluating work; interviews and recommends staff to be hired; counsels and disciplines staff; works with staff to develop and implement new and changed systems. Develops and reports on performance measures.
- Manages staff that monitor all aspects of the managed care, utilization review guidelines, including verification of managed care benefits; managed care concurrent reviews, to ensure that the patient is getting the right care in a timely and cost-effective way, and retrospective reviews, after treatment has been completed.
- Provides analysis and reports of significant utilization trends, patterns, and impacts to administrative staff.
- Consults with clinical and medical directors, and other professionals to develop improved utilization of effective and appropriate services. Assists in the analyzing of data accumulated at chart reviews and developing practices to accomplish best results and documentation that meets all licensing standards and facilitates payment for services.
- Responsible for monitoring managed care patterns and making recommendations to the program directors on strategies to insure quality care; and ensures implementation of practice guidelines and criteria established by the Medical Director.
- Maintains knowledge base and understanding of current JCAHO, AHA, New York State OASAS, Medicaid and Medicare regulations.
- Will randomly sit in on Treatment Planning, Census Management and other appropriate meetings.
- Will implement a consistent process for UR in both buildings that will standardize procedures, forms, and the appeals process.
- All other duties assigned by supervisor.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Effective leadership, management and communication skills. Coordinates tasks and communications between the UR staff, clinical staff, managed care organizations and administration. This manager must also be able to make sound, informed decisions, think strategically and is expected to regularly develop process improvements to ensure the long-term success of the organization.
EDUCATION and/or EXPERIENCE:
Registered Nurse or Licensed Certified Social Worker Quality Healthcare Provider (QHP). 5 years experience in behavioral health documentation and/or utilization review. Effective leadership and management skills and requires strong communication skills, customer service and sound organization skills. Proficient in Microsoft Excel (formatting formulas, managing data, and filtering results).