Manager, Utilization Management

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Contributes to the Hospital’s mission by supporting proper classification and a safe plan of care. This professional licensed position will have an impact on finance and growth by classifying patients’ status appropriately and supporting the workflow and care plan to ensure the delivery of high quality, safe patient care while maintaining an expected length of stay within budget. This role is critical to the denial management, utilization review, and discharge planning process and will support the evolution towards a system approach in this realm.

This role functions in a high integrity manner and as a case management and utilization expert, collaborating interdepartmentally to educate and improve processes to appropriate classify patient status, which ultimately improves reimbursement. The Utilization Management Specialist will impact the patient experience and quality of care by daily rounding and working with the patient/family and provider to establish the best plan of care for discharge.

This role will also cover in the absence of Director of Care Transitions

Job Description:

QUALIFICATIONS:

Education:

Required:

Bachelors of Science in Nursing

Preferred:

Master’s Degree in a health care field

5 year requirement:
Masters Degree in Nursing or relevant field

Experience

Required

• At least five (5) years of experience as a Registered Nurse

• At least five (5) years of experience in inpatient case management and utilization review

• Experience in staff education in both the formal and non-formal setting presenting

• Certification in Case Management earned within one year of hire.

Preferred

• Demonstrated leadership experience

• Demonstrated ability to drive change resulting in achievement of hospital and department goals

• Ability to participate at system level meetings ensuring workflow design aligns with hospital operations resulting in achieving clinical, financial, and operational goals.

Other Skills/Knowledge

Required

• For safety and quality reasons, must be able to read, write and communicate effectively in English with patients, visitors, vendors, and fellow members of the hospital team.

• Computer skills

• Use of Leveling tools, including Inter Qual criteria

Preferred

LICENSES, REGISTRATIONS, CERTIFICATIONS

Required

• Current license to practice professional nursing from MA Board of Registration

Preferred

• Professional certification

POPULATION SPECIFIC REQUIREMENTS

Neonate, Infant, Children, Adolescent, Adult, and Geriatric

OTHER

JOB REQUIREMENTS:

Professional Commitment Requirements: Keep abreast of developments in the field and/or licensure through continuing education, participation in professional organizations or a combination of both.

Schedule requirements: Contingent on the needs of the department.

Travel requirements: Local travel may be needed for training, education, and participation in system level meetings.

REPORTING RELATIONSHIPS:

• Reports to the Director, Care Transitions.

Direct Reports

• Utilization Review Team

JOB FUNCTIONS

Consistent with the WE CARE principles and inherent in a hospital environment, employees must be flexible in meeting patients’ and the Hospital’s needs. While the list below describes the primary functions of this job, all employees at Winchester Hospital need to recognize that an essential element of their job is the ability to respond to unanticipated and/or changing situations. This may result in assuming responsibilities or tasks which are not on this list.

Perform medical necessity surveillance, concurrent clinical reviews, patient status oversight and management, and coordination with financial team to ensure proper reimbursement.

The Utilization Management Specialist promotes the…