Utilization Review Manager (RN)

Job Description

Job Description

Location : Based in Forest Hills, PA (15221), covers all Community LIFE locations

Schedule : 7 : 30am-4 : 00pm Mon-Fri with flexibility in schedule to respond to emergent needs

Summary of Job Duties : The Utilization Review Manager (URM) directs and manages the utilization management functions of all responsible staff. In consultation with the Director of Nursing Services, the URM develops and implements policies and procedures for utilization management in compliance with established Community LIFE policies and recognized industry standards. The URM establishes and maintains service authorization and utilization management protocols implemented by Utilization Management Coordinators based on medical criteria and necessity that supports clinically sound and consistent level of care coverage decisions. The Utilization Management strategy assures the delivery of the “right care at the right time in the right location.” The individual who qualifies for this position must demonstrate the knowledge and skills necessary to assess, plan care for and provide services to frail elders. The URM will have contract oversight and serve as a liaison with network hospitals, nursing facilities and skilled home health care agencies.

Required Education : Bachelor’s degree required, MSN preferred.

Required Certifications / Licensure : License and current registration to practice as Registered Professional Nurse in the state of Pennsylvania. Valid PA driver’s license.

Required Experience : Minimum of 10 years of experience in a managed care environment with significant experience in the various principles of utilization management (concurrent review, discharge planning, pre-certification) and dealing with long term care clients and / or the frail elderly. Minimum of 5 years of experience in health care administration, medical or case management. Experience in data management and proficiency in analyzing and presenting data in a meaningful way.

Required Skills & Abilities :

• Ability to analyze, compile, and report data in a meaningful way.
• Ability to research and develop sound clinical protocols for authorizing inpatient services.
• Strategic and tactical perspective on how to significantly improve operational performance
• Proven experience in creating, implementing and managing care and disease management programs to respond to members’ needs and population trends
• Ability to interpret and apply guidelines to effectively control medical costs
• Proficient verbal and written communication skills.
• Personal computer skills including spreadsheet, database, and graphics software (Excel, Word, PowerPoint).
• Self-organization skills; attentiveness to detail and accuracy.
• Ability to effectively work independently.
• Excellent clinical and assessment skills.
• Thorough knowledge of current acute and long-term care nursing practice and principles of medial management.
• Ability to plan and coordinate nursing care for individuals, families and groups.
• Ability to establish and maintain cooperative working relationships.
• Ability to accept and utilize guidance.
• Ability to perform duties in accordance with ANA Code for Professional Nurses.
• Acceptable physical and mental health to carry out the responsibilities of the position.

About us :

Community LIFE is a program of all-inclusive care for the elderly, committed to empowering older adults to remain at home while preserving their dignity, independence and quality of life. Our program brings the region’s experts in geriatric medicine and care together to work as a team in specialized Day Centers, to help older adults enjoy the highest quality of life possible. Our professionals are committed to keeping older adults independent, and in their homes. Our wide range of services are designed to meet the varied needs of seniors, and include medical care, social services, meals, activities, transportation and much more.

Benefits :

Community LIFE offers a generous benefit package, including Medical, Dental and Vision insurance, Life insurance, Disability insurance, 5 weeks Paid Vacation, Paid Holidays, 403(b) retirement plan, Tuition Reimbursement, Mileage Reimbursement, Employee Appreciation events, and more!