The Utilization Review Manager develops, coordinates, and implements the Utilization Plan and Program of Fremont Hospital. The UR Manager ensures that the development, implementation and evaluation of department policies and procedures are in compliance with all corporate, JCAHO, federal, state and local regulations. The UR Manager serves as a patient rights advocate for the facility. The UR Manager oversees and manages the U.M. staff. The UR Manager maintains a productive, professional relationship with the medical staff, management team and all other departments. The UR Manager performs other duties as assigned. The Utilization Review Manager reports to the Hospital CEO.
Education: Graduate of an accredited RN Program or Master's Degree in Social Work, Psychology, Counseling, or other Human Service field. Bachelors' Degree in Nursing from an accredited school is preferred.
Licensure: Registered Nurse with current California license and CPR.
Experience: Five years of clinical experience in a psychiatric inpatient setting is preferred. Prior experience in the utilization and review function is highly preferred. Previous management experience in supervision or administration is preferred. The ability to organize tasks related to the accomplishment of hospital goals and objectives. Ability to work in a professional manner with physicians, mental health professional, outside agencies, and support staff.
Additional Requirements: Ability to work with child, adolescent, and adult populations as demonstrated through educational accomplishment or work experience. A working knowledge of JCAHO patient rights standards, and any other applicable federal and state laws and regulations governing mental health care facilities relating to Patients rights and utilization review. Successful completion of CPR Certification and successful completion of a professionally recognized Crisis Preventative Intervention (CPI) course within 30 days of employment and prior to assisting with restraining procedures. Able to work overtime and flexible hours.
JOB DESCRIPTION AND PERFORMANCE EVALUATION
The below statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of employees classified on this job.
□ Job Description:
I have reviewed and received a copy of the job description and understand how I will be evaluated on my Performance Evaluation
□ Performance Evaluation (complete the self-evaluation within ten (10) days of receipt):
I have reviewed this document, discussed its contents with my manager and had the opportunity to make written comments. My signature indicates that I have been advised of my performance status and does not necessarily imply that I agree with this evaluation.
KNOWLEDGE, SKILLS, AND ABILITIES
THIS SECTION DESCRIBES WHAT KNOWLEDGE, SKILLS AND ABILITIES AN EMPLOYEE IN THIS POSITION SHOULD CURRENTLY POSSESS. THIS LIST MAY NOT BE COMPLETE FOR ALL KNOWLEDGE, SKILLS AND ABILITIES REQUIRED FOR THIS POSITION.
1. Ability to prioritize, plan, direct, and manage the day-to-day activities of the Utilization and Review department.
2. Ability to identify and solve work related problems of the department staff.
3. Knowledge of Patients Rights, advanced directives, adult and child abuse laws, and emergency detention and use of application.
4. Knowledge of Child Protection Agencies and notification process.
5. Ability to conduct a complaint investigation and follow through to resolution of complaint.
6. Knowledge of requirements involving patient rights under other applicable agencies.
7. Knowledge of the growth and development stages of children, adolescents, adults and geriatric patients.
8. A working knowledge and understanding of JCAHO and other standards relating to utilization review, information management, and patient rights issues.
9. Ability to maintain professionalism in dealing with patients, families, physicians, outside agencies, other department staff members and the departmental staff directly supervised.
10. A working knowledge of hospital, corporate, and personnel policies and procedures.
11. Knowledge of external review organizations (i.e. Managed Care, Medicare, Medicaid, state gatekeeper for Medicaid).
12. Knowledge and utilization of crisis intervention techniques.
13. Knowledge of patient assessment, family motivation and treatment planning techniques.
14. Knowledge of complex patient care planning.
15. Excellent leadership and negotiation skills.
16. Excellent organizational and interpersonal communication skills.
17. Skill in interacting with multiple individuals with diversified roles and perspectives.
18. Skill in organizing and prioritizing workloads to meet deadlines.
19. Skill in telephone etiquette and paging procedures.
20. Excellent customer relations skills.
21. Effective oral and written communication skills.
22. Ability to communicate effectively with patients and co-workers.
23. Ability to prioritize heavy workloads.
24. Ability to adhere to safety policies and procedures.
25. Ability to tolerate ambiguity, uncertainty and change.
26. Ability to use good judgment and to maintain confidentiality of information.
27. Ability to work as a team player.
28. Ability to demonstrate tact, resourcefulness, patience and dedication.
29. Ability to recognize the importance of adapting to the various patient age groups (adolescent, adult and geriatric).
30. Ability to work in a fast-paced environment.
31. Ability to meet corporate deadlines.
32. Ability to react calmly and effectively in emergency situations.
PHYSICAL, MENTAL, AND SPECIAL DEMANDS
THIS SECTION DESCRIBES HOW AN EMPLOYEE IN THIS POSITION CURRENTLY PERFORMS THE FUNCTIONS OF THIS POSITION. MODIFICATIONS TO THE MANNER IN THAT THIS JOB MAY BE PERFORMED WILL BE REVIEWED ON A CASE-BY-CASE BASIS.
1. Ability to stand or walk up to six hours, sit for up to two hours.
2. Ability to spend 20% of the workday outdoors in temperatures varying from 30° F. to 100° F. and 80% of the workday indoors in temperatures varying form 60° F. to 85° F.
3. Ability to occasionally push/pull wheeled carts from 200 lbs. (i.e. crash carts, patient on stretchers or in wheelchairs).
4. Ability to frequently lift and carry up to 10 pounds; occasionally lift and carry up to 100 pounds.
5. Ability to see well enough to read written materials.
6. Ability to discern a variety of odors.
7. Ability to handle hazardous/infectious waste on an occasional basis.
8. Ability to work in an environment where the noise level is frequently high; where chemicals are frequently used in cleaning; where mechanical and electrical hazards may occasionally be present; and where dust, mist and steam are frequently generated in housekeeping tasks.
9. Ability to respond to exposure to blood and body fluids.
MACHINES, TOOLS, EQUIPMENT, AND OTHER WORK AIDES:
THIS SECTION DESCRIBES THOSE MACHINES, TOOLS, EQUIPMENT AND OTHER WORK AIDE AN EMPLOYEE IN THIS POSITION MUST BE ABLE TO USE.
1. Computer and various software packages.
2. Telephone and paging system.
4. Medical records.
5. Copy machine.
6. Policies, procedures, plans and program manuals.
COMPETENCY - a competency is a measurable and/or observable cluster of knowledge and skills demonstrated by behavior and performance.
PR = Policy Review PC = Program/Class Completion OT = Other, Define ____________________
PT = Proficiency Testing D = Discussion with employee
1=Improvement Needed/Minimal Experience/Meets Some Standards
2=Meets Standards/Satisfactory Performance/Performs Without Supervision
3=Exceeds Standards/Commendable Performance/Acts as a Resource Person
ORGANIZATIONAL EXPECTATIONS AND COMPETENCIES
THIS SECTION IS TO BE USED TO EVALUATE THOSE JOB QUALITIES AND COMPETENCIES, WHICH ARE A FUNDAMENTAL REQUIREMENT FOR AN EMPLOEE TO MEET EXPECTATIONS AS A FREMONT HOSPITAL EMPLOYEE.
Performance and Quality Improvement:
Supports department, facility, and company wide quality/performance improvement goals and objectives.
Understands Fremont Hospital's PI methodology of Plan, Do, Check, and Act.
Maintains confidentiality of facility employees and patients information.
Demonstrates behavior that supports Fremont Hospital's/PSI's mission, vision, and values.
Participates in continuing education and demonstrate initiative in keeping up-to-date with relevant professional developments.
Verbally promotes the image of Fremont Hospital and PSI in a positive manner to residents and co-workers.
Practices and maintains a safe working environment and reports any unsafe working conditions.
Participates in quality improvement programs.
Volunteers to pick up extra assignments in emergencies.
Assist in integrating new staff into work group through mentoring and coaching.
STANDARDS OF PERFORMANCE
THE ESSENTIAL JOB FUNCTIONS ARE CATEFORIZED UNDER THE JCAHO STANDARDS OF PERFORMANCE.
Develop, implement, and maintain the Utilization Management Program and Plan, policies and procedures.
Remain current with admission, continued stay, and discharge criteria and implement it into the UR Plan, policies and procedures.
Ensure that updates on admission, continued stay and discharge criteria are forwarded to Assessment Dept., physicians, and administrative staff.
Maintain a variety of statistics and logs pertaining to the utilization review function.
Appeal cases with outside appeal agencies as necessary.
Coordinate denial/appeal process with Patient Accounts Dept.
Attend multi-disciplinary treatment team and provide input regarding discharge planning.
Evaluate timeliness and appropriateness of patient's treatment via review of medical record.
Complete medical record audits as needed.
Assist in the selection, placement and retention of department personnel.
Conduct job performance evaluations on department staff. Counsel personnel on performance issues and take disciplinary action if warranted.
Participate in the orientation of employees and teach training classes involving utilization review and patient rights.
Promote, support, and exhibit good customer service.
Adhere to hospital, corporate, and personnel policies and procedures.
Serve on various hospital committees as assigned.
Perform other duties as assigned by the CEO.
Recognize that everyone is uniquely multicultural (belonging to many subgroups, which define the person's belief system, behavior, language work ethic, etc.).
Maintain a nonjudgmental attitude toward the food preferences and notions of cleanliness of other groups and willingness to accommodate whenever possible.
Show an awareness of differences in communication styles and cultural and spiritual values and work ethics. Show an ability to refrain from assuming that everyone is "just like me" or judging others by one's own codes of behaviors.
Demonstrates an understanding of relevant cultural values and customs.
Demonstrates an ability to integrate cultural diversity needs into specific job responsibilities, i.e., appropriately and respectfully toward patients and staff different from oneself.
Works harmoniously with internal and external customers to inspire teamwork and cooperation in achieving mutual goals.
Interacts with all patients and other staff in a professional and respectful manner at all times.
Demonstrates effective communication methods (written, verbal, non-verbal, and electronic) when dealing with all customers.
Deals with interpersonal conflict by assertively speaking with other party first and using appropriate channels to resolve conflict.
Supports and assists others in conflict situations with all customers.