It's more than a career, it's a calling
MO-REMOTE
Worker Type:
Regular
Job Highlights:
PRIMARY RESPONSIBILITIES
- Provides oversight to the department leaders and staff in managing fiscal resources for the utilization management program. Maintains and leverages ongoing business relationships with internal departments to facilitate business goals and objectives. Acts as an operational leader/liaison between the system, physician advisors, patient care team, and the payors throughout the patient stay to ensure patient level of care status and continuation of medical necessities are documented.
- Manages internal and external stakeholder relationships to communicate progress, risks, issues, and mitigation to Care Transformation (CT) Lead to proactively drive resolution. Escalates issues, risks, and disputes to the CT leadership, as appropriate.
- Develops and maintains statistical information that demonstrates fiscal responsibility in allocation of system resources.
- Reviews service levels and associated performance reporting to ensure progress and compliance with requirements to the agreements. Monitors vendor service levels, tracks vendor practices, and leads corrective actions in collaboration with system revenue cycle leaders and other departments. Monitors effectiveness of policies, guidelines, rules, and regulations and vendor compliance and provides recommendations based on reviews, analytics, and results.
- Collaborates with appropriate stakeholders to address performance that does not meet expectations for select service levels and performance improvement criteria. Participates in and provides leadership for select system quality initiatives (e.g., denial prevention, denial management, audits, compliance, readmission prevention, mortality, Patient Safety Indicators/Hospital Acquired Condition (PSI/HAC), care variation, and clinical programs).
- Maintains an ongoing awareness of regulatory requirements. Participates in accreditation process with surveying and accreditation bodies as the expert on utilization management (UM) policies and practices.
- Collaborates with other system and ministries in identifying process improvement opportunities. Oversees the system utilization management committee with physician leadership. Tracks and trends department Key Performance Indicators (KPI) using systematic and timely review and evaluation.
- Delegates tasks to ministry UM leaders and staff. Oversees annual reviews the competencies of the UM staff through audits, assigned education and training. Reviews results of monthly audits of UM documentation to ensure standards are maintained.
- Recruits, engages, develops, leads, and manages assigned staff.
- Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's scope of service.
- Works in a constant state of alertness and safe manner.
- Performs other duties as assigned.
EDUCATION
- Graduate of an accredited school of nursing RN license required
EXPERIENCE
- Seven years' experience, with five years' in leadership
REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS
State of Work Location: Illinois, Missouri, Wisconsin, or Oklahoma
- Registered Professional Nurse (RN) – Illinois Department of Financial & Professional Regulation (IDFPR)
- OR
- Registered Nurse (RN) Issued by Compact State
- OR
- Registered Nurse (RN) – Missouri Division of Professional Registration
- OR
- Registered Nurse (RN) - Oklahoma Board of Nursing (OBN)
- OR
- Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services
Named 150 Top Places to Work in Healthcare 2023 - Becker's Healthcare
Named One of America's Greatest Workplaces for Diversity 2023 - Newsweek
Named One of America's Greatest Workplaces for Women 2023 - Newsweek
SSM Health is a Catholic, not-for-profit health system serving the comprehensive health needs of communities across the Midwest through a robust and fully integrated health care delivery system. The organization’s 40,000 team members and more than 12,800 providers are committed to providing exceptional health care services and revealing God’s healing presence to everyone they serve.
With care delivery sites in Illinois, Missouri, Oklahoma and Wisconsin, SSM Health includes 23 hospitals, more than 300 physician offices and other outpatient and virtual care services, 13 post-acute facilities, comprehensive home care and hospice services, a pharmacy benefit company, a health insurance company and an accountable care organization. It is one of the largest employers in every community it serves.
To request additional information, confidentially submit your interest, or nominate a fellow colleague, please contact:
Angela Jones
Executive Talent Acquisition
Angela.Jones1@ssmhealth.com
SSM Health is committed to equal employment opportunity based on race, color, religion, national origin, gender, sexual orientation, gender identity, pregnancy, age, physical or mental disability, veteran status, and all other statuses protected by law.
#LI-Remote
Job Summary:
This is a remote position. SSM Health currently offers remote work for residents in the following states: MO, WI, IL, OK, AL, FL, GA, IA, IN, KS, KY, LA, MI, NC, SC, TN, TX, UT, VA, WV.
Job Responsibilities and Requirements:
Provides strategic leadership, development, and supervision to utilization management department, provides interprofessional collaboration with system departments and the ministries. Facilitates process design and continuous process improvement quality initiatives to ensure operational efficiencies and improved performance outcomes across the system. Aligns practice of utilization management with standard work to reduce variation and ensure compliance with system and regulatory practices.
Work Shift:
Day Shift (United States of America)
Job Type:
Employee
Department:
8764070033 System Care Coordination
Scheduled Weekly Hours:
40
SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity,pregnancy, veteran status, or any other characteristic protected by applicable law. Click here to learn more.
