Nurse Manager - Utilization Management

The RN Manager, Care Management provides leadership, direction, and resource management for case managers and social workers in the inpatient and ambulatory settings. The RN Manager effectively resolves utilization review and denial management issues, provides leadership in resolving psychosocial issues, and removes barriers and complexities for case managers and social workers to effectively facilitate safe discharge planning. The RN Manager collaborates internally and externally to maximize patient flow and mitigate reimbursement issues. 

• Collaborates internally with pre-certification staff, admitting and billing office personnel, contracting staff, house supervisors, risk management, physicians, and specialty departments that impact needs during the inpatient stay and through the provision of an effective, safe discharge. 
• External collaboration includes but is not limited to health plans, providers, and vendors that impact needs during the inpatient stay and through an effective, safe discharge. 
• This individual has a strong working knowledge of Medicare/Medicaid, regulatory compliance mandates, auditing agencies, national coverage determinations (NCDs) and local coverage determinations (LCDs). 
• Possesses knowledge of various payer sources, benefits, and limitations and understands and applies utilization management standards from the patient's point of entry through discharge. 
• The RN Manager assists in developing and creates ownership for the department's vision and planning, fostering teamwork and an open creative environment for staff. 
• The RN Manager coordinates, implements, and evaluates staff development and manages staff performance proactively and decisively. 
• The RN Manager supports staff leadership activities, including community involvement and participation in committees and research. 
• This individual must demonstrate knowledge of the principles of growth and development of the life span and appropriately interpret information relative to the patient's specific needs.
• The RN Manager, Care Management supports leadership amongst the staff through support of activities that include staff development, community involvement, and participation in committees and research. 
• The American Nurses Association (ANA) Nursing Scope and Standards of Practice, the ANA Code of Ethics for Nurses, and the Commission for Case Manager Guideline provide the basis for practice. 
• This role is eligible for TN sponsorship. Successful sponsorship will require state licensure and completion of the VisaScreen or equivalent certification.
• This role provides direct supervision of utilization management and denials. This manager is part of a leadership team that covers post-acute program, and ambulatory case management. 

Minimum Education and/or Experience Required: 

• Graduate of a bachelor’s degree in nursing required, a Master’s degree in nursing is preferred. Minimum of three years of nursing practice or progressive leadership experience required. 
• Must be highly motivated, flexible, innovative, and self-directed. Excellent communication, interpersonal skills, and proficiency with computers.

Additional Experience and/or Qualifications: 

• Five years of hospital-based case management, including discharge planning and utilization review experience is preferred. 
• Knowledge of Medicare/Medicaid and other payer sources, benefits, and limitations. 
• Strong inpatient utilization review knowledge related to status and process.