Utilization Manager Jobs in Maine (NOW HIRING)

Description

4CM02

PVH employment application required. All job offers contingent upon background check and completion of pre-employment physical.

This is an "as needed" position utilized to cover gaps in coverage including vacations, leaves of absence, and other instances of unfilled shifts.  

Per diem employees are required to work a minimum of 3 shifts, within a 3-month period.

JOB FUNCTIONS:

Responsibilities include, but are not limited to:

1. Collaborates with members of the health care team.

2. Demonstrates the ability to organize and carry out duties without direct supervision.

3. Demonstrates understanding of care management philosophy and principles through

application of problem-solving techniques and critical thinking skills to facilitate positive outcomes.

4. Oversees the communication of the plan of care to patient/family, physicians and other members of the healthcare team.

5. Successfully maintains the "big-picture" view of a case and ensures that actions take place to ensure this view is consistent.

6. Possess the ability to stay focused on the desired outcomes, without getting sidetracked by tasks or activities that are not contributing to keeping/getting a patient/project on track.

7. Exhibits excellent interpersonal communication skills.

8. Facilitates daily multidisciplinary team care conferences/huddles.

9. Appropriately communicates necessary information to the Director of Inpatient/ED and/or the Chief Nursing Officer.

10. Constructively participates in PVH committees.

11. Is a resource to staff and physicians regarding appropriateness of admission and continued stay levels of care (including related documentation requirements).

12. Ensures assessments are holistic in nature and consistently address the patient's physical and psychosocial health, environment, support systems, educational needs, and financial resources.

13. Accurately evaluates the progress of the patient/family on a daily basis and with the healthcare team, modifies plans in order to achieve established goals.

14. Makes arrangements to ensure all services and supplies required by the patient post discharge

will be available.

15. Recognizes and is able to comfortably address conflict that is an obstacle to a patient receiving coordinated care.

16. Ensures that patients are discharged neither sooner nor later than is clinically appropriate.

17. Is a resource to staff and physicians regarding quality-of-care concerns and
criteria/guidelines/protocols utilized in care planning and resource utilization.

18. Coordinates interdisciplinary care conferences for complex cases when goals of the health care team members and the patient/family are not mutually acceptable.

19. Succeeds as a change agent by recognizing and effectively intervening to address unresolved problems that interfere with achieving pre-established patient care goals.

20. Expedites the scheduling of tests and procedures as required to move patients through the system in a fiscally responsible way.

21. Demonstrates understanding of payer prior approval requirements, the various health care delivery systems and payer plan contracts.

22. Ensures/oversees that the patient/family understands the discharge plan and that the educational needs regarding the discharge plan have been met.

23. Performs accurate, age-appropriate and timely assessments within the next business day of the patient entering the facility.

24. Demonstrates accountability for job responsibilities and actions taken by being proactive and completing assignments thoroughly and in a timely manner.

25. Maintains knowledge of and participates in department and hospital wide performance improvement activities.

26. Utilizes available time to participate in QI, maintain statistical records, complete special projects.

27. Uses work time in a professional and responsible manner.

28. Attends scheduled department meetings.

UR:

1. Provides well coordinated, appropriate, and timely UR services.

2. Maintains an expert working knowledge of the payer/reimbursement systems.

3. Collaborates with the physician and health care team to achieve documentation to support medical necessity thereby achieving approved days and certification.

4. Effectively and appropriately channels pertinent information between the healthcare team, physician and insurance companies.

5. Is an expert in utilization management thereby providing support/assistance in the areas of utilization review and levels of care.

6. Expedites the scheduling of tests and procedures as required to move patients through the system in a fiscally responsible way.

7. Recognizes and intervenes when either over or under utilization of services is identified.

8. Accurately transmits required information to third party payers in a timely manner, as appropriate.

9. Actively manages the denial/appeal process.

10. Plans, sets priorities and manages care to achieve specific clinical and fiscal outcomes.

11. Effectively facilitates communication between the physician and others in order to achieve established goals for the patient/family regarding UR.

12. Ensures collaboration with the physician and health care team to implement the plan of care in a maximally efficient and effective manner.

13. Review and/or complete medical necessity criteria for every admission.

Quality Improvement: Actively participates in the Hospital-wide Quality Improvement Program, actively supports and implements Department-specific Quality improvement initiatives and projects, recommends process improvement as appropriate, reports any quality issues in service delivery and consistently commits to a focus on quality improvement and organizational excellence.

Disaster Management: As an employee of Penobscot Valley Hospital, the position has an inherent role to care for our community members when in need. To this regard, the incumbent will be expected to participate in emergency/disaster preparedness planning and drills as requested. When called upon during a real life disaster/emergency event, the incumbent will be expected to participate in the Hospital's response to this event, within the scope of professional and personal ability to do so.

Requirements

A degree in social work, nursing or human services field including but not limited to sociology, rehabilitation counseling, and psychology, LSW or RN preferred. One year of social services background/experience in a healthcare setting preferred. Awareness of federal, state, and local requirements, also resources, systems, and processes; awareness of what benefits each provider to what populations in what time frames, and how to access each by telephone, pager, fax, w-mail, etc. Adaptable to provide direct and indirect support to each of the functions supported. Judgement and initiative in prioritizing needed focus and tasks to meet patient and unit needs.   

Benefits  

PVH has a Section 125 Cafeteria Benefits Plan and pays a portion of the cost of our health plan, dental, basic life, and disability insurance for employees for 30+ authorized hours, and provides partial subsidy for dependent health insurance.  Part-time employees are eligible to receive dental, life, and disability coverage and are eligible to participate in the health insurance plan. Other benefits include a 403(b) plan and earned time off accrual.