The Utilization Management Lead is responsible to develop and maintain a high performing, effective, efficient team within a framework that supports operational policy, procedure, and organizational goals. Supports the collection and management of all associated data, reports, auditing requirements, policies, procedures, and database management.
This is a full-time, benefit-eligible position. UTSW is proud to offer a comprehensive benefit package that includes:
Paid (zero premium) medical coverage for employees starting first day
State of Texas defined-benefit pension plan
Generous Paid Time Off (vacation & sick leave plus 14 paid holidays)
On-site childcare centers, dependent/elder back-up care and work/life programs
Utilizes clinical expertise to interpret medical policy and medical criteria and educates/coaches’ staff appropriately according to their job roles and functions. Conducts clinically based discussions with the treatment team. Leads teams by encouraging them to take ownership of their work processes and understand their role within the company. Helps teams to understand high-level business objectives and how their work is essential to the achievement of these objectives. Manages performance of team members and delivers timely and appropriate performance feedback and training.
RN with valid TX license is required.
BSN from an accredited institution is required.
Three (3) years’ previous full time direct clinical nursing experience or five (5) years’ experience in utilization management, understanding medical criteria, medical guidelines, medical policy, and Medicare/CMS regulations.
Manages day-to-day business area activities, provides leadership, coaching and training to team members, sets clear goals and expectations and manages performance as needed.
Creates a positive work environment that fosters teamwork, empowerment, accountability, and superior customer service .
Acts as a resource for team members, providing assistance/guidance on clinical and/or system issues, benefits, and work processes and procedures specific to departmental needs.
Identifies trends, determines root causes, and takes action to resolve issues and initiate necessary process and procedural changes to improve internal and external customer satisfaction.
Ensures all departmental and clinical reports and necessary reviews are completed in a timely manner.
Maintains accountability for achieving targeted results and communicates regularly with leadership regarding workloads, issues, projects, monitoring of team performance and staffing needs.
Responsible for the application and compliance with all regulations, standards or other regulatory requirements applicable to departmental operations. Formulates corrective action plans to address any areas of non-compliance.
Must maintain current knowledge in applicable clinical areas, standards and certifications (where required) and keep abreast of trends related to the health insurance industry (i.e. CPT, HCPCS, ICD-9, and ICD-10 coding, etc.).
Facilitates meetings and conducts formal presentations for staff and/or other groups as needed.
Serves as liaison between the staff, physician advisors and key operational areas as necessary to identify and resolve issues.
Manages consistency review process for all UR staff. Results of the reviews are provided to individual staff for input into performance evaluations. Collaborates with manager to identify trends within the department and to plan additional training.
Promotes and encourages staff to utilize essential elements of the nursing process in their job functions: assessment, planning, implementation, coordination, monitoring, and evaluation.
Responsible for new employee training and orientation to the department’s processes and systems and monitors the quality and productivity performance of new employees until desired levels of quality and productivity have been achieved.
Assesses relevant training needs for all staff and individuals, produces training materials and strategies and manages the training delivery, measurements and appropriate follow up.
Presents and facilitates training and development programs utilizing various instructional methodologies and media; allowing sufficient time for practice and facilitating group interaction to attain stated objectives
Performs other duties as assigned.
KNOWLEDGE, SKILLS, & ABILITIES
Demonstrated leadership skills (i.e. training, mentoring, coaching or assisting peers with issue resolution) or previous experience in a leadership role is required.
Interqual, and/or Milliman knowledge
Intermediate Microsoft Word, Excel, Outlook, Powerpoint, Access, Adobe, Visio, and Project skills
Demonstrated ability to allocate, monitor, and control resources while delegating and monitoring workloads
Demonstrated ability to manage large caseloads in a fast-paced environment while building and enhancing team productivity
Demonstrated professionalism and leadership skills along with the ability to develop, direct, and support staff
Familiarity with Epic
Work is performed primarily in a hospital/clinical setting as well as a general office setting.
Any qualifications to be considered as equivalents in lieu of stated minimums require prior approval of the Vice President for Human Resources Administration, or his/her designee.
This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information
This position is security-sensitive and thereby subject to the provisions of Texas Education Code §51.215.
UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.
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