Nurse Manager, Utilization Management in Care Coordination, Winston Campus "Job Details"
Winston-Salem, NC, United States
- Medical Center Blvd, Winston Salem, NC, 27157, US
07/12/2021, 4:03 PM
Utilization Management, Care Coordination
Full time, salaried
Wake Forest Baptist Health is a pre-eminent academic health system based in Winston-Salem, North Carolina. Wake Forest Baptist’s two main components are an integrated clinical system – anchored by Wake Forest Baptist Medical Center, an 885-bed tertiary-care hospital in Winston-Salem – that includes Brenner Children’s Hospital, five community hospitals, more than 350 primary and specialty care locations and more than 2,500 physicians; and Wake Forest School of Medicine, a recognized leader in experiential medical education and groundbreaking research that includes Wake Forest Innovations, a commercialization enterprise focused on advancing health care through new medical technologies and biomedical discovery.
Working within the established policies and procedures of Wake Forest Baptist Health the Manager will be responsible for functional and operational case management activities performed by the multi-disciplinary team. The Manager’s focus will be on the timely provision /flow of specific clinical information to third party payers to help ensure certification /approval of inpatient and post discharge days. The manager will monitor quality, the consistent and appropriate use of evidence-based criteria, set documentation standards for the team and ensure that the staff are complying with all legal and regulatory standards. The Manager will monitor and evaluate the operations of the department and will recommend changes to the Associate Vice President of Care Coordination to maintain and improve the effectiveness of the department. The manager is also responsible for quality, functional excellence and contributions to accomplishing strategic and operational objectives. The Manager will develop and maintain a professional and collaborative working relationship with the Department’s Medical Director. The Manager will contribute to the development of collaborative relationships with post-acute providers to ensure timely and efficient transitions of care.
Education / Experience:
Graduation from an accredited School of Nursing. BSN and Masters in Healthcare required. Knowledge of national, regional and local case management trends. Five years of clinical experience required. Previous experience in utilization review preferred. Academic medical center experience preferred.
Licensure, Certification and / or Registration:
- Current licensure to practice as a Registered Nurse in the State of North Carolina.
- Certification in case management highly recommended within 2 years.
Implements and supports the hospital’s mission, the philosophy of the Department of Care Coordination, and divisional objectives.
Manages and facilitates quality practice. Conducts audits of staff activities to assure compliance with departmental policies and to assess adherence to productivity standards. Identifies and implements changes that enhance the effectiveness of patient care delivery. Ensures compliance with legal and regulatory agency standards.
Manages departmental utilization management operations. Assures that medical necessity reviews are completed on a regular basis in accordance with all state and federal regulations and the Utilization Management Plan. Demonstrates proficiency in applying nationally accepted evidence based criteria to assure appropriate hospital level of care service. Serves as a resource to RN case managers in determination of medical necessity and patient status including observation and inpatient admission status.
Collaborates with payers, physician advisor and team to reconcile payer-issued denials.
Collaborates with other medical center departments to assure compliance with state and federal regulations. Communicates with outside regulatory and third party payers to assure delivery of fiscally responsible care.
Compiles specific reports upon request to document and track utilization trends and outcomes.
Assures staff development activities, promotes and maintain clinical competence. Completes employee performance reviews and assures staff receive timely, meaningful feedback. Mentors and guides staff. Serves as a resource for all staff.
Communicates with physician advisor, departmental leadership and other medical center departments regarding barrier to patient placement and/or patient progression of care. Proactively communicates problems that impede the patient treatment process.
Maintains current knowledge of state, federal and commercial payer requirements and guidelines. Assures departmental compliance with the CMS Conditions of Participation. Assures staff compliance with federal regulations, guidelines and mandates (including but not limited to Condition 44, 2 Midnight Benchmark, Medicare Appeals) through ongoing audits of team member’s reviews. Provides education on new regulations and current laws as well as policy changes in order to assure quality metrics.
Develops and maintains systems for seamless efficient delivery of care. Coordinates activities with other disciplines, departments and outside agencies.
Assures that customer expectations of patients, families, physicians and colleagues are addressed. Communicates customer service expectations and assists in development and implementation of strategies to enhance customer satisfaction.
Sets departmental documentation standards for the team and assures staff compliance. Completes audits to assure staff documentation of utilization management activities, including retroactive reviews, are timely and complete.
Assists with management of departmental resources, assuring budgetary compliance and communications regarding variances. Provides justification for requests for staff/department needs.
Ensures age/developmentally appropriate patient care in provided in accordance with Age Specific Care Guidelines for the specific age groups served.
Skills and Qualifications:
- Demonstrates leadership attributes and the ability to foster professional development in staff
- Demonstrates organization, planning and delegation skills
- Resilient and flexible in a changing environment
- Practices consideration for all employees
- Displays excellent interpersonal, communication and written communication skills
- Results orientation with concern for process
- High proficiency with computer skills
- Group facilitation and public speaking skills adaptable to groups of varying sizes
- Reaching with arms
- Finger and hand dexterity
- Lifting, carrying, pushing and or pulling:
- 20 lbs. maximum
- 50 lbs. maximum
- 100 lbs. maximum
- Clean, well lit, comfortable environment (office space)
- May be exposed to infectious and contagious diseases
- Subject to many interruptions
- Subject to irregular hours
- Sets departmental standard of mutual respect among colleagues in the work setting
Wake Forest Baptist Health and Atrium Health have joined forces in a strategic combination that will enhance care, transform medical education and create economic opportunity for countless lives in North Carolina and beyond. As a part of that combination, the two health systems will be integrating technology and platforms, including our career sites.
This means that although you are applying on the Wake Forest Baptist Health Career Site, you receive communications from the Atrium Health Recruitment Team. Please know that this is an expected process, and thanks in advance for your flexibility.
Wake Forest Baptist Health (www.WakeHealth.edu) is a nationally recognized academic health system in Winston-Salem, North Carolina, with an integrated enterprise including educational and research facilities, hospitals, clinics, diagnostic centers, and other primary and specialty care facilities serving 24 counties in northwest North Carolina and southwest Virginia.
It comprises: a regional clinical system with more than 300 locations, 2,100 physicians and 1,535 acute care beds; Wake Forest School of Medicine; and Wake Forest Innovations, which promotes the commercialization of research discoveries and operates Innovation Quarter, an urban research and business park specializing in biotechnology, materials science and information technology. Wake Forest Baptist’s clinical, research and educational programs are consistently ranked among the best in the country.
About the Team
Wake Forest Baptist Health's mission is to improve the health of our region, state and nation by:
- Generating and translating knowledge to prevent, diagnose and treat disease.
- Training leaders in health care and biomedical science.
- Serving as the premier health system in our region, with specific centers of excellence recognized as national and international care destination.