Manager, Utilization Review

Under the administrative supervision of the Director of Utilization Management, manages the daily activities of the Utilization Review Nurses and Case Management Extenders to ensure effective processes and successful completion of utilization management, payer communication, authorizations for care provided, and timely progression of care and discharge planning. Supports the efforts of HIM and Patient Accounts by ensuring timely, accurate, and complete data entry in multiple information systems and denials prevention and management. Brings issues with legal, risk management, or ethical implication to the attention of Director in an expedient manner. Functions as key contact point for Hospital and maintains excellent working relationships with payers. Participates in strategic planning for the department, working as a member of the case management leadership team. Interviews applicants, makes recommendations for hiring and salary for new employees, completes performance appraisals in a timely manner and employs disciplinary actions as required. Communicates with other departments in the hospital at a high level to ensure that information flow is timely, appropriate and accurate. Represents the department on Committees as indicated. Responsible for performing job duties in accordance with the mission, vision, and values of Tampa General Hospital and the principles of quality improvement.

Technical Knowledge, Skills, and Abilities

• Develops the procedures required for an efficient, effective utilization review program, to successfully manage the implementation of that program and concomitant activities of the Utilization Review Nurses and Case Management Extenders in a fast paced, dynamic environment.

• Maintains current knowledge of all local, state, and federal regulatory requirements related to care coordination responsibilities.

• Has an in-depth understanding of utilization management guidelines used to evaluate patient care and status.

• Leads and participates in departmental and organizational performance improvement activities including the utilization of variance and denial data to assist hospital leadership in identifying opportunities for improvement.

• Develops effective processes to ensure accurate and timely admission and continued stay reviews, appropriate authorizations for care and quality communication with payers and caregivers. Positive impact on revenue is demonstrated by the successful fulfillment of these duties.

Essential Functions

• Monitors, reports outcomes/patterns/trends; guides/supports Team Lead.

• Assists Director with reporting and case presentations. Participates in mtgs per Director.

• Identifies opportunities for UM Strategic planning.

• Leads and participates in departmental and organizational performance improvement activities including the utilization of variance and denial data to assist hospital leadership in identifying opportunities for improvement.

• Assesses the quality of work performed in the department, providing feedback to employees with the goal of continuous improvement.

• Serves as a resource to staff to support, manage, and/or resolve issues related to utilization/denials management, and hospital admission authorization.

• Completes necessary research to gather appropriate details/information prior to making decisions when complex issues are presented.

• Submits staff performance management report, maintaining productivity at approved standards.

• Oversees and guides operations towards efficiency, effectiveness

• Performance Appraisal/Competency of each staff member. Determines remediation, education needs and performance action plans.

• Guides the TL within determined scheduling parameters. 

• Establishes consistent practice with scheduling to maintain optimal staff/review coverage needs.

• Collaborates closely with Case Management and Revenue Cycle to align with overall organizational action plans/goals. 

• Five (5) years of clinical experience and a minimum of five (5) years experience in utilization management and/or case management required and may substitute for the degree. 

• Licensed as a Registered Nurse in the state of Florida