Job Summary

This role is a member of the integrated community care team (ICCT), providing clinical and performance oversight of a transitional care management team that is comprised registered nurses. The manager of utilization management (MUM) understands the level of care and medical necessity process, discharge planning, care coordination and integrated case management supports for members currently admitted at an inpatient facility. The MUM works closely with the center medical director and the Program Manager of Utilization Management to identify and implement integrated processes to improve outcomes.

The MUM is responsible for oversight of daily operations of the utilization management and transitional care management team including ensuring compliance with internal and NCQA timeliness and care plan/documentation standards, case file/performance reviews (e.g., case file audits, ride alongs, 1:1 coaching), participation in interdisciplinary care team meetings and rounds. The manager of utilization management leads team meetings and maintains team morale through virtual and in-person activities. The MUM is responsible for interviewing, hiring, and ensuring onboarding/training needs are met for new hires. Effectiveness is measured by value-based care outcomes including member engagement, admission and readmission rates, length of stay, bed days and hospital follow-up completion rates.

Duties and Responsibilities

• Lead a transitional care team comprised of licensed clinical staff and/or unlicensed staff/peer supports.
• Develop payor and facility relationships with leadership and case management departments for collaborative member management at time of inpatient stays and during care transitions.
• Facilitate rounding with payor and facilities to review and problem solve for members at risk for unnecessary or avoidable utilization.

• Leverage evidenced based guidelines such as MCG or InterQual for discharge planning and optimize appropriate level of care decisions.

• Closely collaborate with community and center-based colleagues to deliver integrated care under a collaborative care model through interdisciplinary care team meetings, case consultations, etc.
• Use daily operational reports to monitor team performance and proactively identify low performing staff and/or processes requiring improvements.
• Proactively identify low performing staff and implement coaching and/or performance improvement plans to meet performance/quality standards.
• Oversee clinical staff development and performance that results in person-centered care planning, SMART goals, clear and consistent documentation, use of evidence-based disease management and chronic care protocols in combination with therapeutic approaches to care including motivational interviewing, trauma informed care, and harm-reduction strategies.
• Oversee all caseloads assigned to the transitional care management team to ensure member follow up, timely and accurate documentation, and compliance with company, health plan, and NCQA requirements.
• Serve as a SME on transitional care and utilization management and to lead the training and adoption of these approaches to member care for the assigned market.
• Host regular 1:1 meetings and team meetings with all direct reports and maintain related documentation.
• Interview, hire, and complete departmental onboarding/preceptorships for new employees in coordination with the Manager of Utilization Management
• Proactively identify and mitigate barriers to team productivity and member care through data analysis, creative problem solving, and process optimization.
• Meet deadlines and manage competing priorities.
• Maintain the security and privacy of all information that is owned by AbsoluteCare or maintained on behalf of the company’s patients, employees, and business partners.
• NOTE: This job description reflects the essential functions of the role and is subject to change. Additional tasks may be assigned, as needed, to support the business needs.
• Promote core values and help positively drive the quality metrics.
• NOTE: This job description reflects the essential functions of the role and is subject to change. Additional tasks may be assigned, as needed, to support the business needs.

Minimum Qualifications

• Must be willing and able to travel up to 80% of the time to local area hospitals, skilled nursing facilities and residential treatment facilities to shadow staff, visit members and build relationships with discharge planners and case management staff.
• Licensed RN by the state in which practicing and abide by all laws, regulations, and requirements.
  • Preference given to RN candidates with extensive experience discharge planning, care transition coordination and medical and behavioral case management in the community. Candidate with CCM or CCTM credentials a plus.
• + 2 years of management experience preferred + 4 years of supervisory experience considered.
• + 5 years experienced in discharge planning and care coordination for continuity in care transitions, strategies for reducing readmissions and chronic condition management interventions a must.
• Experience serving the needs of complex populations, including medically complex, trauma history, mental health conditions, substance abuse, and socioeconomic barriers in an office or community-based setting.
  • Preference given to qualified candidate with multiple settings experience (Inpatient, LTPAC, home health, corrections, community programs and/or human service agencies.)
  • Experience with complex government-sponsored populations preferred, e.g., Medicaid, Medicare beneficiaries.
  • Experience with member engagement, transitions of care, clinical care, and/or case management.
• Experienced in concurrent review for level of care determinations and taking action to transition to other care settings by expediting prior authorizations, leveraging the power of influence, and advocating on behalf of the member.
• Ability to take a creative and innovative approach to problem-solving to aid patients in overcoming barriers to care transitions.
• Excellent computer skills including Microsoft Office Suite (Outlook, Excel, PowerPoint, Word) and electronic medical record documentation required.
• Excellent written and oral communication skills to interact with members, families, community stakeholders, and interdisciplinary team required.
• Ability to meet accreditation and quality standards including, but not limited to NCQA, PCMH, HEDIS through following defined procedures to assess, intervene and document interactions.
• Good leadership skills with proven record of developing and maintaining team morale, high productivity levels, and minimal undesirable staff attrition.
• Ability to work independently and exercise excellent clinical judgement.
• Active unencumbered driver’s license, with automobile insurance, reliable transportation, and ability to work in office and in the community.
• Excellent organizational and time management skills to prioritize and meet deadlines.
• Ability to analyze data to identify and implement process improvements.
• Proven record of ability to lead through change in a dynamic environment.

Working conditions

This job operates in the community and within a professional office environment.  This role requires reliable transportation to commute back and forth between inpatient facilities; and routinely uses general office equipment.

Physical requirements

• Ability to communicate clearly and exchange accurate information constantly.
• Ability to remain stationary for long periods of time.
• Constantly operates computer, keyboard, copy and fax machine, phone and other general office equipment.

• Ability to occasionally move objects up to 20 lbs.

Direct reports

May include any combination of the below:

• Supervisor of Utilization Management
• Transitional Care Manager