DescriptionJOB SUMMARY: The Behavioral Health Utilization Review Manager- RN at LifeStream oversees the utilization review department comprised of three (3) UM Specialists, ensuring the appropriate allocation and use of healthcare resources for behavioral health services. This team of three individuals is dedicated to reviewing clinical documentation, coordinating with healthcare providers, and ensuring compliance with regulatory and funding requirements. The Manager will focus on optimizing patient care, improving service delivery, and maintaining efficient utilization of resources in a non-profit agency setting.ESSENTIAL FUNCTIONS and RESPONSIBILITIES: The list of essential functions, as outlined herein, is intended to be representative of the tasks performed within this classification with or without an accommodation. It is not necessarily descriptive of any one position in the class. The omission of an essential function does not preclude management from assigning duties not listed herein if such functions are a logical assignment to the position. Leadership and Management:
- Supervise and lead a team of three utilization review specialists.
- Provide training, mentorship, and performance evaluations for team members.
- Develop and implement departmental goals, policies, and procedures.
- Establish and maintain cross-functional relationships with medical and clinical personnel, billing, members of leadership, quality and performance, and risk and compliance.
- Provide guidance and leadership to direct reports, ensure regular individual and team feedback cycle is maintained to support performance maintenance and improvement as needed. In conjunction with human resources, manage any disciplinary matters that may arise.
Utilization Review:
- Conduct comprehensive reviews of clinical documentation to ensure medical necessity, appropriateness, and compliance with payer guidelines.
- Monitor patient progress and treatment plans to ensure timely and effective care delivery.
- Collaborate with clinical staff to facilitate appropriate levels of care and discharge planning.
Compliance and Reporting:
- Ensure compliance with all relevant regulations, standards, and payer requirements.
- Prepare and submit necessary documentation and reports to funding sources, regulatory agencies, and internal stakeholders.
- Conduct regular audits and reviews to identify areas for improvement and ensure adherence to best practices.
Data Analysis and Reporting:
- Track and analyze utilization KPI data to identify trends, areas for improvement, and opportunities for cost savings (e.g., Denial Rates, Authorization Timeliness, Medical Necessity Compliance, Length of Stay (LOS vs. Expected Length of Stay, Appeals Success Rate, Discharge Planning Efficiency, Concurrent Review Timeliness, Readmission Rate, Utilization of Covered Days, Billing Cycle Time, Documentation Error Rate, Payer Mix by Utilization, etc.)
- Provide regular reports and updates to senior management on utilization review activities and outcomes.
- Develop and implement strategies to optimize resource utilization and enhance service delivery.
Quality Improvement:
- Participate in quality improvement initiatives to enhance patient care and operational efficiency.
- Implement evidence-based practices and continuous improvement processes within the department.
- Work collaboratively with other departments to support integrated care and service coordination.
Additional duties as assigned by Leadership.COMPETENCIES: Knowledge, Skills, Abilities, and Motivation (KSAM) required for an employee to be successful.
- Serving Our Consumers: Effectively meeting consumer needs, building productive consumer relationships, and taking responsibility for consumer satisfaction and loyalty.
- Consumer Focus: Building strong consumer relationships and delivering consumer-centric solutions.
- Values Differences: Recognizing the value that different perspectives and cultures bring to an organization.
- Age Specific: Assessment , Interpretation , Interventions, Knowledge, Developmental Stages, and Enhances Family Involvement
- Basic Job Readiness: Reliability, Responsiveness, Courtesy, and Flexibility
- Personal Effectiveness: Communication , Interpersonal skills, Thinking Skills, Self Management
- Organizational Management: Leadership, Linking/Networking, Organizational Participation , CQI Commitment, Compliance, Management of Information, and Safety
- Performance Specific: Assessment , Treatment/Service Planning, Psychosocial Interventions , Crisis Management , Medication Issues, Customer Focus, and Empowerment/Advocacy
- Effective Communication: Clearly conveying information and ideas to individuals and groups in a manner that engages the audience and helps them understand and retain the message.
- Communicates Effectively: Developing and delivering multi-mode communications that convey a clear understanding of the unique needs of different audiences.
- Manages Conflict: Handling conflict situations effectively, with a minimum of noise.
- Continuous Improvement: The ongoing process of achieving positive changes in service and processes in order to improve efficiency and quality.
- Resourcefulness: Securing and deploying resources effectively and efficiently.
- Cultivates Innovation: Creating new and better ways for the organization to be successful.
- Expertise: Demonstrating proficiency of an employee's skill or knowledge within their field of practice.
- Drives Results: Consistently achieving results, even under tough circumstances.
- Leadership: Ability to lead, mentor, and develop a team to achieve departmental and organizational goals.
- Analytical Thinking: Proficiency in analyzing data and making informed decisions to optimize resource utilization and patient care.
- Communication: Strong verbal and written communication skills to effectively interact with staff, patients, and medical and clinical professionals and other stakeholders.
- Compliance: In-depth knowledge of regulatory requirements and the ability to ensure adherence to standards and guidelines.
- Collaboration: Ability to work effectively with multidisciplinary teams to coordinate care and improve service delivery.
- Problem-Solving: Strong problem-solving skills to identify and address issues related to utilization and patient care.
- Detail-Oriented: Attention to detail in reviewing clinical documentation and preparing reports.
WORKING CONDITIONS: Primarily office-based with some travel to various medical/clinical sites as needed. May require occasional evening or weekend hours to meet organizational needs.TRAVEL: Local travel only via automobile required to attend Treatment Team Meetings and other meetings as needed. Must have a valid Florida driver's license and provide evidence of active and adequate auto insurance.PERSONAL QUALITIES: Autonomous, self-directed, detail oriented. Displays proactive leadership in internal as well as, external interactions. Demonstrates high level of cooperation. Promotes a positive image of the Center to the entire community. Proficient in time management. Demonstrates verbal and written communication skills. Comfortable in doing presentations to partner agencies.SPECIAL FACTORS: Possesses the ability to provide immediate direction in crisis situations which require real time solutions. Must demonstrate high level of understanding of the Center's mission and vision. Understands the full array of services provided by LifeStream. Promotes personal and team effectiveness in interactions which will affect the successful outcome of LifeStream's mission. Demonstrates ability to stay abreast of the changing healthcare environment and provide input for effective program enhancements or modifications as necessary or prudent.JUDGMENT/DECISION MAKING: Utilizes established corporate policies and procedures in making decisions. Uses sound judgment in meeting the responsibilities and performing the duties of the position. ESSENTIAL SKILLS: Strong knowledge of utilization review processes, payer and insurance guidelines, and regulatory requirements. Excellent leadership and team management skills. Proficient in data analysis and reporting. Strong organizational and problem-solving abilities. Effective communication and interpersonal skills. Ability to work collaboratively with clinical and administrative staff. Proficiency in electronic health record (EHR) systems and utilization management software.EDUCATION & EXPERIENCE:
- Education: Bachelor's degree in Nursing, Social Work, Psychology, or a related field required. Master's degree preferred. Current/Active licensure as a Registered Nurse, Licensed Clinical Social Worker, or equivalent preferred.
- Experience: Minimum of 3 years of experience in utilization review case management within hospital and/or behavioral health and 3 years of either active field nursing, social work, or psychology working directly with patients/clients/persons served. 3+ years of supervisory or management experience required. Experience working in a non-profit or community-based healthcare organization preferred.
- Driving Requirements:
- Must be Over the age of 21 required
- Minimum of 5-years driving experience required
- Possess a Valid FL Driver's license (within 30 days of hire if currently do not possess)
- Possess a continuously valid US Driver's license for the past three years, from date of issue required
- Safe Driving record required
TRAINING & DEVELOPMENT: Completes all requirements according to Individual Training Plan within the first six months of hire and annually. Other training and/or professional development may be assigned due to evolution of programs.