The Program Manager, Utilization Review / Case Management has 24 hour accountability for the operational and personnel management of the UTMB UR/CM program. Serves as liaison and assists in the resolution of issues that cross multiple departments and/or services to ensure optimal quality, cost, and service/outcomes. Supports and actualizes the UTMB Utilization Review / Case Management program by utilizing clinical knowledge, expertise, approved criteria, protocols and guidelines to ensure care is appropriate and provided in a cost-effective manner.

Major Duties / Critical Tasks:

• Supervises the operational management of the Utilization Review / Case Management program to ensure high quality, cost effective service/outcomes, and a safe and efficient work environment.
• Monitors the work performance of the Utilization Review Case Management staff and provides guidance as necessary.
• Prepares the Utilization Review / Case Management work schedule to ensure adequate staff coverage and completion of all assignments.
• Develops and facilitates effective and efficient workflow processes for the Utilization Review / Case Management program according to established Policies and Procedures.
• Monitors and facilitates appropriate utilization of resources.
• Tracks and reports trends of inappropriate resource utilization to Director and /or Assistant Director of Utilization Review / Case Management.
• Maintains a documentation system of all review activities and enters appropriate variances using approved variance codes.
• Provides back-up support for telephone Utilization Review to ensure adequate staff coverage.
• Assist staff with problem resolution of Utilization Review issues
• Provides leadership for the Utilization Review / Case Management program and promotes teamwork.
• Assists with the implementation of Utilization Review / Case Management Policies and Procedures.
• Assists in the orientation of new personnel and completes a formal preceptor plan in accordance with Utilization Management Policy 09.04.
• Identifies and facilitates quality improvement for the Utilization Review / Case Management program.
• Maintains a mechanism for the review of quality of care issues arising during concurrent review, and identifies areas of potential medical liability.
• Educates the Medical Staff and Nursing Staff on the Utilization Review / Case Management program and provides specific information related to case types, including financial data.
• Maintains clinical expertise in specialty area and/or general nursing.
• Provides assistance with clinical issues for non-nursing Utilization Review Case Management staff.
• Contributes to the overall success of UTMB Managed Care Organization.
• Demonstrates a high level of productivity and dependability.
• Actively promotes the professional development of self and others.
• Adheres to internal controls as established by department.
• Performs a variety of marginal duties not listed, to be determined and assigned as needed.

Graduation from an accredited school of Professional Nursing and current Texas Nursing Licensure as a Professional Registered Nurse. 

Minimum of five years full-time wage earning experience as a Professional Nurse in a health care setting with at least two years in the utilization review area and at least two years of Supervisory and/or Management experience.

Knowledge, Skills, & Abilities

• Must be self-motivated, willing and able to learn multiple aspects of the job.
• Able to demonstrate both written and verbal communication skills
• Demonstrate excellent interpersonal skills and telephone etiquette.
• Demonstrates history of accuracy, tenacity and attention to detail.

Standard office equipment.

Working Environment:

• May involve traveling. May involve occasional shift work and weekends as needed to accommodate operations 24 hours a day, seven days a week.
• Able to work under stress and be emotionally capable of coping with complex and/or changing activities.
• Standard office environment including exposure to air conditioning, heating, and outside elements to and from work and during meal break times.