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The stated pay scale reflects the range as defined by the collective bargaining agreement between Sharp HealthCare and Sharp Professional Nurses Network, United Nurses Associations of California/Union of Health Care Professionals, NUHHCE, AFSME, AFL-CIO. Placement within the range is based on years of RN experience.

What You Will Do
As a member of the System Integrated Care Management (ICM) team the Transfer and Admissions Utilization Manager (UM) partners with the Centralized Patient Placement Center (CPPC) RN's to review external and internal transfer requests and direct admission requests. This position supports utilization review functions to ensure appropriate patient status and assists with repatriation and post-stabilization reviews for patients before the patient is bedded, during the episode of care and supports other members of the System Centralized Utilization Management team to ensure final status reconciliation. This position ensures timely and proactive interaction with the CPPC team, admitting/attending physician, payer, physician advisor and other members of the interdisciplinary care team as appropriate. This position coordinates activities with Revenue Cycle while ensuring compliance with all local, state and federal regulations governing utilization review activities and/or care management. Expected outcomes include meeting or exceeding planned divisional and organizational goals while enhancing patient satisfaction through support of appropriate billings. This position requires superior critical thinking, demonstrated exceptional knowledge of evidence-based guidelines, and best-of-class service delivery as exampled by meeting support needs, technical resource and service, as well as performance and quality. This position supports the ICM model of patient-centric care. Acts as a mentor for new hires and orientees under the direction of the ICM Centralized UM Leadership team. This position supports the 24/7 System Centralized UM Department.

Required Qualifications

• Bachelor's Degree in a health-related field.
• 3 Years Utilization Management or case management within a hospital or payer setting.
• 3 Years acute care nursing experience.
• 2 Years recent pertinent clinical experience as defined by the CBA.
• California Registered Nurse (RN) - CA Board of Registered Nursing

Preferred Qualifications

• Bachelors Degree in Nursing
• 3 years Utilization Management "and" Case Management -strongly preferred
• Experience with the nationally recognized medical necessity review criteria by MCG or InterQual - strongly preferred.
• Experience and understanding of federal and state regulations governing utilization management.
• Accredited Case Manager (ACM) - American Case Management Association (ACMA)
• Certified Case Manager (CCM) - Commission for Case Manager Certification

Essential Functions

• Collaboration and Teamwork
  
  Represent management (as requested) at system and site level meetings.
  Partner with the CPPC and Revenue Cycle team to act as a consult for external and internal transfer and direct admission requests to ensure medical necessity and payer considerations are reviewed.
  Perform initial and concurrent review on intent to bed or bedded patients. Works collaboratively with system emergency departments (ED), attending physicians as well as the physician advisor. Assists in the repatriation and post-stabilization process to mitigate denials. Engages and confers with the physician advisor on call as needed.
  Identifies and escalates cases not meeting criteria for admission or concurrent stay. Works proactively to identify solutions when these cases are identified. Advises the physician advisor of these cases and works to mitigate denials.
  Reviews hospitalized patients with the Physician Advisor and/or facility UR chairperson as requested or required by plan/group/payer.
  Identifies and reports upon as appropriate any emerging variances or trends counter to the division and organizational objectives.
  Maintain records and statistics as required, i.e. bed days, discharges, re-admissions, diagnoses.
  Ensures accurate and timely completion of all documentation requirements.
  Coordinates transfer of 'out-of-network' patients, when indicated.
  Maintain confidentiality of all patient and Utilization Management information.
  Participate in ICM Care Conferences as requested.
  Work collaboratively with other members of the health care team as well as the respective medical groups to facilitate the utilization management process.
  Identify and refers situations needing immediate intervention to UR Manager, Physician Advisor, as appropriate.
  Participate in system or site-level utilization review activities and projects as needed.
  Maintain a log and report of all high risk, long stay patients and/or otherwise outlier patients (as requested).
• Communication
  Facilitates information sharing and project coordination where appropriate between teams and facilities.
  Develops collaborative relationships with external transfer centers, nursing departments, payers, hospitals, and Physicians.
  Consistently models behavior, service delivery, and communication in a manner so as to distinguish the Centralized UR as an ever-role model for efficiency, superior customer service and problem solving.
  Uses communication strategies with individuals and groups that result in achievement of intended outcomes and always positive relationships.
• Maintain a high degree of professionalism
  Demonstrate the ability to make decisions, take appropriate accountability with action and follow tasks through to completion.
  Recognize and analyze the implications of new situations and develops workable solutions to maintain productivity and morale.
  Act as a best-practice role model in demonstrating the customer service standards of the organization.
  Demonstrate a commitment to personal growth and development by participating in external activities related to professional goals.
  Respond cooperatively to managers and staff members in other departments to promote teamwork.
  Attend departmental meetings as appropriate and contributes ideas for improving efficiency, productivity and patient satisfaction.
• Professional development
  Drives change at the individual contributor level to improve overall process and team performance.
  Identifies and seeks out opportunities to grow individual competency and skillset in the area of utilization review, integrated care management and transition planning.
  Seeks out opportunities to take on department projects or identifies performance improvement activities.
  Maintain a high-quality work product.
  Remains ever aware of regulations, laws, practices, standards and other influencers to care management practice.

Knowledge, Skills, and Abilities

• Proficiency with information systems and computer programs such as word, excel, etc.
• Advanced clinical skills in area of expertise.
• Proficient knowledge and understanding of utilization management.
• Demonstrated understanding and abilities for superior service management and relationship advancement skills.
• Demonstrated understanding and competency with evidenced-based guidelines.
• Self-directed and demonstrates ability to prioritize.
• Demonstrated ability to remain flexible in rapid change environment and current health care dynamic climate.
• Work collaboratively with interdisciplinary team.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class