Supervisor

Purpose Statement / Position Summary

This position has responsibility for the day to day operations and decisions of the assigned clinical services department activities as they relate to Utilization Management of referrals for ambulatory services. The supervisor will be responsible for primary supervision of utilization nurses and support staff. This position will support the UM Manager and Director in achieving Medical Management initiatives for cost saving, implementing growth and development plans while supporting the strategic goals of the foundation.

Essential Functions and Responsibilities of the Job

• Demonstrates consistent performance, monitor staff for implementation of Utilization Management regulation, guidelines and standards to meet CMS, NCQA and health plan compliance.
• Ability to apply common sense, collaboration and communication in the assessment, development and deployment of all assigned tasks and responsibilities.
• Consistently demonstrates ability to practice and model a positive communication style that fosters open and honest feedback and contributes to a team centric environment that produces top quality results.
• Sets and models high performance standards with integrity, ensures effective and productive work ethics, and teamwork for the Utilization Management team.
• Be present and available to team members for problem solving and resolution management.
• Follow company policies, procedures and directives
• Interact in a positive and constructive manner
• Prioritize and multitask

• Manages day to day oversight of activities associated with Utilization Management nurses and supports UM Manager in the oversight of coordinators for the management of referrals, regulatory compliance, critical analysis of criteria and clinical history to make referral determinations for approvals and or denials.
• Identify, develop and conduct training for staff and/or coordinate with trainer for new hires or when additional training is needed
• Assign, manage, and/or handle special projects delegated by Manager and Director.
• Develop and implement quality and productivity standards then establish the expectations with the staff in the performance of their jobs.
• Interface with other departments to resolve issues associated with cases managed by the staff.
• Participate in quality improvement activities for departmental specific processes.
• Evaluate personnel to coach, counsel and/or discipline employees as necessary to improve performance.
• Monitor time and attendance of assigned staff.
• Provide support to U.M. Manager, Director, and Medical Director.
• Ability to problem solve to logical conclusion and demonstrates initiative and responsibility

Experience

• Must be licensed as a Registered Nurse.
• Minimum of 5 years experience in utilization management and Managed Care.
• Minimum 2 years supervisory experience preferred
• Excellent communication skills, including written and verbal
• Knowledge of regulatory requirements, health plan contracts, delegation requirements, Medicare, Managed Care, utilization management.
• 3 years’ work experience working with evidence-based guidelines, criteria (i.e.: MCG, Interqual, Hayes); health plan medical policy / clinical coverage guidelines.
• Working knowledge of Microsoft applications – Word, Excel
• Ability to perform complex problem solving and project management.
• Flexibility in work schedule

Education

• Bachelor’s degree preferred or equivalent years of experience and education.