Registered Nurse-Manager of Utilization Management, Full Time Days
Cape Fear Valley Health
Summary
Participates in and oversees the operational and personnel activities as it relates to Utilization Management needs and requirements. Responsible for the coordination and management of denials and subsequent outgoing appeals between payers and Cape Fear Valley Health System. Supports a collaborative coordinated process among departments within the community, health system, physician, and support staff to promote effective management and cost containment of patient care across the healthcare continuum. Fosters teamwork and integration of services for the staff in Coordination of Care and the customers served. Adheres to patient experience initiatives and champions customer service excellence.
Job description
Major Job Functions
- Leads, coordinates and oversees the workload of the Utilization Management RNs
- Reviews and recommends policies and procedures in relation to Utilization Management
- Maintains updated knowledge of Medicare and Medicaid regulation changes and provides communication and facilitates new process changes as necessary to maintain compliance as it relates to Utilization Management activities
- Audits staff’s Admission and Concurrent Reviews for accurate application of criteria
- Provide education to staff as a result of comprehensive analysis of data gathered and trends identified
- Responds proactively to demand letters received from all payers, ensuring that contacted timeframes for appeals are met
- Serves as Medical Necessity Reviewer in conjunction with Physician Advisor for Recovery Audit Contractor Team
- Educates on and facilitates compliance with Joint Commission requirements, audits, compliance, and record maintenance
- Identifies and develops department and individual performance audit tools to measure compliance and quality
- Identifies opportunities and solution sets and strategies to improve utilization management departmental processes to meet the evolving needs of specific patient populations, hospital, and community
- Other duties as assigned
Minimum Qualifications
Education and Formal Training
- Associate’s degree in Nursing required
- Bachelor's degree in Nursing preferred
- Current Registered Nurse licensure in North Carolina or Compact state licensure required
Work Experience
- 3 years’ experience in Utilization Management required
- 1 year of Case Management experience preferred
- 1 year prior experience with data and statistical analysis preferred
- 3 years in managed care claims/reimbursement or other healthcare field preferred
- Must have management experience in Utilization Review, experience with insurance claims.
- Must have an understanding of working with a revenue cycle.
- Must understand Epic and Epic reporting.
- Must be able to build reports to manage staff and improve upon an already standing UM committee.
- This position requires working every 4th or 5th weekend.
Knowledge, Skills, and Abilities Required
- Proficiency in reading, writing, and speaking the English language
- Knowledge of professional nursing principles, clinical processes, and clinical interventions
- Working knowledge of Medicare guidelines, as they appear in Federal Register, pertinent to inpatient hospital and ambulatory services
- Ability to perform medical record reviews interpreting, abstracting, aggregating, analyzing, and reporting complex clinical data obtained from medical records
- Knowledge of clinical practice guidelines and the appropriateness of clinical interventions
- Knowledge and ability to implement a quality improvement process
- Strong analytic, data management and research skills
- Excellent interpersonal communication and negotiation skills
- Ability to communicate effectively and work with people of all social, economic, and cultural background
- Self-motivated, proven written, telephonic, and electronic communication skills
- Assertive and persuasive interactions with customers, peers, management, and core staff served
- Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components
- Understanding of criteria and measurement outcomes
- Knowledge of third-party payor requirements including managed care, reimbursement, and utilization management
- Proficiency with various computer programs, to include Microsoft Office, EPIC, InterQual, MCG, Teams, Webex
- Working knowledge of Coordination of Care, Medical Management, Utilization Review, Performance Improvement, Criteria-Based Management
- Ability to demonstrate leadership, respect, and team building
- Flexible, open-minded, and adaptable to change
Requirements
- Associate’s degree in Nursing required
- Current Registered Nurse licensure in North Carolina or Compact state licensure required
- 3 years’ experience in Utilization Management required
- Must have management experience in Utilization Review, experience with insurance claims
- Must have an understanding of working with a revenue cycle
- Must understand Epic and Epic reporting
- Must be able to build reports to manage staff and improve upon an already standing UM committee
- This position requires working every 4th or 5th weekend
- Proficiency in reading, writing, and speaking the English language
- Knowledge of professional nursing principles, clinical processes, and clinical interventions
- Working knowledge of Medicare guidelines, as they appear in Federal Register, pertinent to inpatient hospital and ambulatory services
- Ability to perform medical record reviews interpreting, abstracting, aggregating, analyzing, and reporting complex clinical data obtained from medical records
- Knowledge of clinical practice guidelines and the appropriateness of clinical interventions
- Knowledge and ability to implement a quality improvement process
- Strong analytic, data management and research skills
- Excellent interpersonal communication and negotiation skills
- Ability to communicate effectively and work with people of all social, economic, and cultural background
- Self-motivated, proven written, telephonic, and electronic communication skills
- Assertive and persuasive interactions with customers, peers, management, and core staff served
- Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components
- Understanding of criteria and measurement outcomes
- Knowledge of third-party payor requirements including managed care, reimbursement, and utilization management
- Proficiency with various computer programs, to include Microsoft Office, EPIC, InterQual, MCG, Teams, Webex
- Working knowledge of Coordination of Care, Medical Management, Utilization Review, Performance Improvement, Criteria-Based Management
- Ability to demonstrate leadership, respect, and team building
- Flexible, open-minded, and adaptable to change
Benefits
- Relocation assistance
Company overview
Cape Fear Valley Health is a comprehensive regional healthcare system based in Fayetteville, North Carolina, serving southeastern North Carolina and surrounding regions. Established in 1956, it has grown to become North Carolina's 8th largest health system, operating as a private not-for-profit organization with 7,500 employees and over 1,000 physicians. The system encompasses eight hospitals with 988 total beds, including Cape Fear Valley Medical Center, Highsmith-Rainey Specialty Hospital, Bladen County Hospital, Hoke Hospital, and Harnett Health facilities. Annually, the system serves more than 1 million inpatient and outpatient visits across its network of over 150 locations. Cape Fear Valley Health specializes in cardiac care, cancer treatment, surgical services, neuroscience, pediatrics, rehabilitation, orthopedics, and behavioral health. The organization has earned numerous national recognitions including Healthgrades Top 100 Hospital for Cardiac Care, IBM Watson Top 50 Cardiovascular Hospital, and The Leapfrog Group Grade-A for Patient Safety. With a mission to provide exceptional healthcare for all patients, the system emphasizes patient-centered care, innovation, and community service while maintaining multiple disease-specific certifications from The Joint Commission.