Remote Manager Utilization Management Population Health (RN) – Illinois
- Clinical License RN
- State(s) IL
Schedule Details/Additional Information:
Primarily a remote position with some flexibility to travel in Northern IL and Greater Chicago. Primarily M-F, first shift, but some support may be needed after business hours.
Oversees the development and operations of the Population Health Management Programs for Advocate Aurora Health. Manage care coordination across health care continuum by integrating various teams: wellness screening, acute hospital care, out of network admissions, outpatient embedded case management, transitional unit, home health, and chronic disease management program. Manage and direct Utilization Management UM staff in providing oversight care for patients via relationships with such areas as skilled nursing facilities, hospice, home health agencies, providers, and community-based programs. Manage staff who provide coordination of non-network hospital admissions and facilitate patient transfers back into network or next level of care. Demonstrate stated measures of clinical quality and patient safety through effective utilization management techniques.
* This is a primarily remote position with some travel in Northern Illinois and Greater Chicago.
- Initiates and maintains relationships with hospital Care Management and Medical Management staff to facilitate successful hospitalist/inpatient care management programs. Through full and partial-risk contracts, manages clinical responsibility and global financial risk. Understands current hospital practices. Sensitive to various factors in the environment which make implementation of a utilization management program especially challenging.
- Responsible for the management/maintenance of the relationship with the hospitals (some which are not Advocate Aurora Health facilities). Responsible for interfacing with inpatient and outpatient Care Management departments. Works with UM nurses and care management to review and analyze readmissions rates, explore opportunities to improve transitions to home care and Post-Acute Network Skilled Nursing Facility network and other lower levels of care. Manages problem resolution with large system providers.
- Evaluates and supervises staff’s compliance with department standards, policies and procedures, as well as regulatory agencies and contractual requirements. Develops and implements appropriate policies and procedures and is responsible for staff compliance with Managed Care Organization and regulatory requirements. Evaluates staff requirements in meeting denials, appeals, quality improvement and reporting requirements. Supports and participates in utilization management meetings; including development of meeting agendas, audit summaries, utilization reports and committee minutes
- Reviews data and interpretation of the utilization management statistical key indicators. Monitors big cost claimants. Participates in appropriate committees to develop system-wide initiatives, keep abreast of Managed Care Organization requirements and act as a liaison to insurance companies. Reviews and understands Managed Care Organization’s (payer) contracts and implements necessary medical management procedures to fulfill obligations of contracts.
- Directs and supervises Utilization Management staff to assure efficient/effective operations, which promote quality and comprehensive care for members. Responsible for strategic planning of integration of inpatient, SNF, outpatient network, home health and other services. Manages staff who oversee transitions between inpatient and outpatient care and/or catastrophic case management. Has responsibility to ensure that a complex variety of medical management plans are executed by staff and serves as an expert resource as supervisors and case managers provide majority of patient’s inpatient and nursing facility care.
- Evaluates current practices at SNF makes recommendations and develops strategic plans for more efficient/effective care. Establishes relationships with all medical management staff and physicians at Advocate Aurora Health to resolve issues related to the care management program. Evaluates and presents data to ensure Advocate Aurora Health will meet the short and long-term goals for their sites, consistent with the overall organization’s specified and focused objective.
- Addresses utilization trends and implements appropriate interventions. Assures stable operating platform from which to deliver effective and efficient services including but not limited to insuring workflows, information systems, operating processes, resources and policies and procedures are appropriately maintained. Collaborates with management team to develop implementation plans that convert strategy to operating tactics.
- Develops “best practices” standards to ensure consistency among staff for Advocate Aurora Health business. Utilizes data from inpatient care database to effect change in the inpatient management of patients. Conducts meetings with supervisory staff on a weekly basis to promote staff education and communication. Provides orientation and performs employee evaluations for supervisors. Develops Outpatient Community Support network.
- Performs human resources responsibilities for staff which include interviewing and selection of new employees, promotions, staff development, performance evaluations, compensation changes, resolution of employee concerns, corrective actions, terminations, and overall employee morale.
- Develops and recommends operating and capital budgets and controls expenditures within approved budget objectives.
- Responsible for understanding and adhering to the organization’s Code of Ethical Conduct and for ensuring that personal actions, and the actions of employees supervised, comply with the policies, regulations and laws applicable to the organization’s business.
- Nurse, Registered (RN)
- Bachelor’s Degree in Nursing.
- Typically requires 5 years of experience in utilization management. Includes 1 year of supervisory experience in utilization management.
- Delegated audit and payer experience highly preferred.
Knowledge, Skills & Abilities Required:
- Good verbal and written communication skills, including public speaking and presentations. Excellent interpersonal communication skills. Ability to work independently. Self-directed. Effective leadership skills. Demonstrated knowledge of evolving health care delivery environment. Experience in managed care financial risk business. Ability to understand and interpret multiple contracts and contractual obligations and regulations.
- Registered Nurse license issued by the state in which the team member practices.
Physical Requirements and Working Conditions:
- Position requires travel. May be exposed to weather and road hazards. Exposed to normal office environment. Operates all equipment necessary to perform the job. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.
This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.
Advocate Health Care is the largest health system in Illinois and a national leader in clinical innovation, health outcomes, consumer experience and value-based care. One of the state’s largest private employers, the system serves patients across 11 hospital locations, including two children’s campuses, and more than 250 sites of care. Advocate Health Care, in addition to Aurora Health Care in Wisconsin and Atrium Health in the Carolinas, Georgia and Alabama, is now a part of Advocate Health, the third-largest nonprofit, integrated health system in the United States. Committed to providing equitable care for all, Advocate Health provides nearly $5 billion in annual community benefits.