Assistant Director, Utilization Review (On-site) bei Nexus Enterprises LLC

Description

Job Summary

The Assistant Director, Utilization Review is responsible for assisting the Director, Utilization Review with the leadership, supervision and training of the Utilization Review and Quality Departments, as well as for the collection, aggregation, analysis and reporting of complex production and quality assurance data. The data will be used to support the efficient utilization of administrative nursing resources and review improvement activities. In addition, the Assistant Director will collaborate closely with leadership and staff to support departmental goals, strategies, programs, and projects for continuous improvement. 

Essential Job Functions

• Works with the Director, Utilization Review to effectively lead, supervise and direct the workload in the Utilization Review and Quality Departments 

• Works with the Director, Utilization Review to collect data necessary to complete performance reviews for each Utilization Review Nurse and Quality Nurse

• Works with the Director, Utilization Review on workflow and production expectations of the Utilization Review and Quality Departments 

• Keeps current with regulation changes and communicates changes to the Utilization Review Nurses and Quality Nurses

• Works with the Director, Utilization Review in strategizing UR and QA Nurse retention and incentive programs

• Works directly with the Director, Utilization Review in the development of educational programs

• Works with the Director, Utilization Review to audit cases completed by nurses in training and provide direct feedback to assist with quality development

• Works with the Director, Utilization Review to oversee case distribution during the training period to provide balanced exposure to types of requests, clients, and state guidelines

• Works with the Director, Utilization Review to provide coverage of call information and clarifications of nurses in training during the first 4 weeks of training

• Performs utilization and quality review on an intermittent basis 

• Conducts pre-authorization, concurrent and retrospective reviews dealing with Medical Necessity from Worker’s Comp system, Group Health, Disability, etc. The review requires evaluation of clinical data documented in laboratory reports, radiology reports, and multidisciplinary progress notes

• Perform a low to moderate amount of research on a case-by-case basis

• Create a high-quality, professional report free of grammar or spelling errors

• Dictates all report information

• Effectively work with all employees and vendors (both orally and in writing)

Requirements

Knowledge and Abilities Requirements:

• Ability to read, analyze, and interpret documents, reports, technical procedures, governmental regulation, and correspondence

• Ability to write routine reports and correspondence; and ability to present information in small groups, and large group situations to management and staff

• Ability to apply proper grammar, spelling, punctuation, and format to typed material. Must have excellent oral and written communications skills

• Comprehension of medical/surgical modalities and imaging techniques

• Ability to analyze clinical documentation in relation to medico-legal review

• Ability to Interpret and apply appropriate guidelines to medico-legal reviews

• Ability to use logic and reasoning to determine and utilize appropriate evidence-based guidelines

• Extensive knowledge of Utilization review

• Demonstrates ability to independently identify and define potential and/or current issues of concern, collect and analyze data, establish facts, draw valid conclusions, and exercise discretion and sound judgment

Education and Experience:

• BSN with 1–2 years’ experience in Managed Care setting

 •Extensive knowledge of Workers' Comp and Clinical Review required

• Experience with various state evidence-based medicine guidelines

• Experience in a previous management role required

• Proficient computer skills; able to navigate through multiple software systems; knowledge of Microsoft Word, Excel, and Outlook 

License and Certification:  

• Possess a current and unrestricted RN license. 

Driving Essential: No

Position Demands:

This position requires sitting, bending, and stooping for up to 8 hours per day in an office setting. Ability to lift and move objects weighing up to 20 lbs. Ability to learn technical material. The person in this position occasionally needs to move about inside the office to access file cabinets, office machinery, etc. Must be able to operate a computer and other office productivity machinery such as a calculator, copy machine, printer, etc. The person in this position frequently communicates with guests, team members, and vendors and must be able to exchange accurate information.

Equal Employment Opportunity (Our EEO Statement):

The Company is a veteran-owned Company and provides Equal Employment Opportunities (EEO) to all Team Members and applicants for employment without regard to race, color, religion, sex, sexual orientation, gender (including gender identity), pregnancy, childbirth, or a medical condition related to pregnancy or childbirth, national origin, age, disability, genetic information, status as a covered veteran in accordance with applicable federal, state, and local laws, or any other characteristic or class protected by law and is committed to providing equal employment opportunities. The Company complies with applicable state and local laws governing non-discrimination in employment. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, promotion, discharge, pay, fringe benefits, membership, job training, classification, and other aspects of employment. 

We are committed to creating an inclusive environment for all Team Members and applicants. We value the unique skills and experiences that veterans bring to our team and encourage veterans to apply.   

Disclaimer:

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of our personnel. All team members may be required to perform duties outside of their normal responsibilities from time to time, as needed.