(RN) Care Management Utilization Review Supervisor - 120058

The Care Management Department Supervisor who focuses on Utilization Review (UR) functions as a subject matter expert in InterQual criteria, for payer specific requirements and acts as a liaison between the Care Management Department, inpatient clinical and ancillary teams. Coordinates training and education needs for the Utilization management and support personnel in the Care Management Department.

Responsible for the onboarding, training and orientation of new and existing staff members. Provides mentorship, coaching and oversight to the Care Managers especially as it relates to the UR functions. Serves as a resource for the Department and may also be assigned units for coverage as needed. Oversees the completion of complex case reviews and the resolution of issues and concerns related to utilization management, quality and documentation integrity. Reviews quality audits and shares audit results in a timely manner with associates, providing necessary education to improve performance.

Facilitates an atmosphere of interactive management and the development of collegial relationships among case managers, social workers, other health care staff and faculty. Responsible for the implementation of the vision, mission, philosophy, core values, evidence based practice and standards of the organization as defined by the department. Represents the department on interdepartmental committees, community agencies, boards, and associations. Responsible for ensuring adequate staffing, assignments and coverage in order to fulfill the unit's business needs. The Supervisor models the mission, vision, and core values of the organization; supports evidence based practice to insure optimal outcomes.

While not required, a cover letter is highly recommended when applying to this position.

• A Bachelor's of Science Degree in Nursing.

• Registered Nurse (RN) license issued by the State of California.

• Current BART certification, or BLS certification at time of hire with commitment to get BART within six months of hire date.

• A minimum of five (5+) or more years of relevant experience.

• Experience and proven success in ability to effectively supervise a team and to manage the complex workflow and multiple priorities involved with care coordination and case management.

• Demonstrated experience with InterQual including a thorough understanding of InterQual criteria.

• Proven experience with Medi-Cal State guidelines, TAR reviews, and CMS regulatory requirements.

• Experience with planning, developing, conducting InterQual training programs for staff members on orientation or ongoing improvement of skills to ensure staff's expertise.

• Excellent written and verbal communication and interpersonal skills including tact, diplomacy, and flexibility in order to work effectively with providers, staff, patients, and community agencies in person and on the phone.

• Demonstrated ability to maintain strong working relationships and communications with physicians and members of the health care team.

• MSN.

• Experience in an acute care hospital setting.

• Previous leadership experience.

• Experience providing education to staff and physicians.

• Certified InterQual Trainer

• Accredited Case Manager or Certified Case Manager (ACM or CCM)

• Clinical Nurse Specialist (CNS)

• Certified Professional in Healthcare Management (CPHM)

• Must be able to work various hours and locations based on business needs.
• Employment is subject to a criminal background check and pre-employment physical.