What is the role of a Utilization Manager at Good Shepherd Rehabilitation Network?

The Utilization Manager position at Good Shepherd Rehabilitation Network is a Full-time or part-time position opportunity in the Medical field.

Where is this Utilization Manager job located?

Philadelphia, Pennsylvania, 19146, United States

What type of employment is offered for this Utilization Manager role?

Full-time or part-time position

What is the expected salary for this Utilization Manager job?

Compensation will be discussed during the hiring process.

How can I apply for the Utilization Manager position at Good Shepherd Rehabilitation Network?

You can apply directly through the application link provided.

Utilization Manager at Good Shepherd Rehabilitation Network

Utilization Manager

JOB SUMMARY
- The utilization manager is responsible for the development of a comprehensive and goal oriented plan of care as it relates to effective utilization of available health services, review of the medical necessity of patient admissions, and review of the medical necessity for continued stay in the hospital; the analysis of patient records to ensure compliance with government and insurance company reimbursement policies, and determining patient review dates according to established diagnostic criteria; Acting as a liaison between the patient, the clinical team, and the payer; the management of individual caseloads of patients that are non-Medicare through completion of concurrent reviews, communication with interdisciplinary team and appealing denied days.
ESSENTIAL FUNCTIONS
- PATIENT/CUSTOMER
  - Essential Accountabilities
    - Ensures communication and collaboration with supervisors and fellow co-workers to serve patients and other customers to the best of his/her ability.
    - Is professional in all actions and appearance
    - Anticipates patients’/customers’ needs and acts accordingly.
    - Works to enhance patient satisfaction
    - Analyzes problems from the customers’ point of view.
    - Honors patient/customer/employee confidentiality.
    - Seeks feedback on how to improve performance and offers constructive feedback, as well.
    - Assist patients and families
    - Applies learning for improved performance.
    - Demonstrates understanding and ownership of how his/her role contributes to achieving the success of the Department and GSPP.
    - Demonstrates a personal commitment to ensuring a clean and safe working environment.
    - Uses resources wisely – as if they were one’s own.
  - Non-Essential Accountabilities
    - Strives to understand and value differences in others’ race, nationality, gender, age, background, experience, and style.
    - Assists in orienting new employees/staff, if/as needed.
    - Attends staff meetings and continuing education in-service training as directed by supervisor.
- PATIENT/EMPLOYEE SAFETY ACCOUNTABILITIES
  - Non-Patient Care
    - Participates in GSPP and Department wide initiatives for Patient /Employee safety
    - Demonstrates an awareness of patient/ employee safety when carrying out daily responsibilities of their position.
  - Patient Care Providers
    - Participates in GSPP and Department wide initiatives for Patient /Employee safety
    - Demonstrates an awareness of patient/ employee safety when carrying out daily responsibilities of their position.
    - Validation of annual competencies required for the position
- OPERATIONS
  - Compares patients’ records to established criteria and confers with medical and nursing personnel and other professional staff to establish legitimacy of treatment and length of stay. Documents admission in appropriate EMR platforms.
  - Reviews patients’ records to assess patient progress, and identifies the need for on-going hospitalization.
  - Proactively addresses level of care issues to ensure appropriate care settings and timely patient flow; elevates issues appropriately.
  - Conducts concurrent stay reviews with third party payers.
  - Continuous collaboration with clinical team and professional staff regarding covered services, and end dates as established by third party providers.
  - Initiates physician advisor review for cases not meeting established criteria for admission and/or continued stay to facilitate appropriate utilization of services.
  - Communicates denials from third party payers to the physician.
  - Coordinates a timely appeal process.
  - Conducts retroactive Place of Service Reviews for Pennsylvania Medicaid recipients. Maintains utilization review logs and appeal logs as needed.
  - Maintains current knowledge of regulations affecting utilization management and utilization review.
  - Facilitates educational programs and advises physicians, and other departments, or regulations affecting utilization management and utilization review.
  - Provides discharge planning coverage for case manager during times of SPTO/USPTO as necessary.
QUALIFICATIONS:
- To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  - Education
    - Practical Nursing Program required
    - Bachelor's Degree in Nursing preferred
  - Work Experience
    - 3-5 years of clinical experience required
    - Experience in utilization management or case management preferred
  - Licenses / Certifications
    - LPN required
    - Registered Nurse license preferred
    - Certified Case Manager (CCM) credential preferred

Utilization Manager at Good Shepherd Rehabilitation Network – Philadelphia, Pennsylvania

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