Department :

11221 Population Health - WI Administration : Care Management

Status : Full time

Full time

Benefits Eligible : Hou rs Per Week :

Hou rs Per Week :

Schedule Details / Additional Information :

Monday-Friday Day Shift Salaried Remote Position

Major Responsibilities :

Complete ongoing routine (e.g., monthly, quarterly) quality audits of the work completed by all UM team members, following frequency and volume audit metrics outlined under the UM department audit policy / plan.

Use the findings / data collected to evaluate the overall team educational needs, share feedback with the team and UM leaders, and deliver team-based education that enhance the team’s understanding and compliance with standard UM practices, and support the achievement of department KRAs / goals

• Conduct more extensive, ad-hoc quality audit reviews, as needed or requested by management, to identify individual gaps in knowledge and understanding of UM workflows, and develop and deliver custom educational interventions to individual UM team members
• Develop and maintain report(s), tables, and charts to evaluate, track and / or trend at a team and individual team member level the accuracy and timeliness of work, and provide summary reports to managers quarterly or as needed
• Assist with the preparation and publishing of the monthly report(s) that track and trend the UM RNs and UMA’s productivity and provide feedback / share concerns with UM leaders as requested / needed.

Meet with UM leadership routinely to review the quality audit findings, share concerns, and develop action plans as needed to meet department goals.

Maintain the educational on-boarding program for all new UM RNs and UMAs and participate in the onboarding process for new hires, while tracking and measuring their progress and learning goals.

Participate in and support any other required educational sessions as scheduled / requested by UM leadership

• Keep current with existing or new UM best practices and workflows, Medicare / Medicaid and commercial payer trends, and any State or Federal regulations pertaining to UM, and ensures the timely development / updating of all new or existing training materials, written guidelines, job aids, manuals, SRGs, and other UM resources
• Ensure the UM staff has timely, unrestricted access to up-to-date UM-related internal and external resources (e.g., CMSs Inpatient Only Lists, Medicare reviewable DX codes, Site specific contacts etc.)
• Launch the Interrater Reliability (IRR) quizzes following the pre-determined testing schedule, and prepare and maintain reports that track and trend the UM RNs’ accuracy with MCG guideline selection and their overall performance with testing
• Participate actively in activities related to the monthly UM department meetings, contribute to the development of the PowerPoint presentations, and deliver education updates and workflow reminders.

Collaborate closely with the UM Leaders and provide assistance with special projects and complete any other duties / tasks as assigned / needed.

Oversee the daily operations of large scale, special UM workflows that are subject to high regulatory risks, and frequent, ongoing external audits (e.g., CMS short stays).

Participate in Epic go-live and post go live planning, training, and enhancement efforts / initiatives as needed. Manage and complete any Compliance request for internal audits.

Licensure :

Nurse, Registered (RN)

Education / Experience Required :

Level of Education : BSN (Bachelor's of Science in Nursing) Years of Experience : 3 years of case management or utilization management experience 3 years relevant hospital nursing, case management, or utilization management or project management experience

Knowledge, Skills & Abilities Required :

Working knowledge in the use of Microsoft Office (Excel, Outlook, PowerPoint and Word) or similar products. Knowledge of the components of quality and acute care patient care needs specifically related to the area / function in which care management will be performed.

Demonstrated working knowledge and accurate application of evidence based, nationally recognized Utilization Review criteria as evidenced by achieving 80% or greater on the annual InterRater Reliability (IRR) competency exam.

Critical thinking skills to analyze and synthesize clinical scenarios as it relates to application of medical necessity criteria.

Excellent analytical and interpersonal communication skills necessary to interact with colleagues, physicians, and third-party payers.

Ability to foster and maintain effective professional relationships with physicians and other professionals in a direct and positive manner.

Ability to manage conflict appropriately and communicating with others in a maner that alligs with Advocate Aurora’s Behaviors of Excellence Assume responsibility for self-development by seeking out opportunities for professional growth and development and being an active participant in department, hospital, and system initiatives.

Ability to be flexible and function well in the everchanging, fast-paced, heavily regulated health care / payer environment, and to comply to expectation of strict adherence to predetermined procedures and processes, and compliance and privacy / HIPAA guidelines Ability to function well in a fast-paced work environment that involves numerous interactions with a wide variety and clinical and non-clinical team members, prioritize independently and manage and address timely multiple simultaneous requests

License / Registration / Certification : RN License in the state in which the team member practices, MCG certification

Physicial Requirements and Working Conditions :

• This position may requires travel, therefore, will be exposed to weather and road conditions.
• Ability to operate all equipment necessary to perform the job
• Manual dexterity required for operation computer and calculator and other equipment necessary to perform. Visual acuity required for facilitating review of written documents / computer screens, medical records, and to record information accurately.

Clear verbal communications and hearing acuity required for receiving instructions and converse on standard telephone. Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone.

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.

Last updated : 2024-04-28