RN Director Of Care And Utilization Management

The Clinical Recruiter Naperville , IL 60540

Posted 2 months ago

RN Director of Care and Utilization Management Chicago

  • Naperville

  • Joliet, Illinois Summary:
    Reports to the Executive Director responsible for developing, coordinating and directing and care management initiatives.
    Works collaboratively with the Medical Director of Population Health, Staff, and its participating physician and allied health providers in the development of standardized clinical evidence-based guidelines and care management systems.
    Responsible for implementing and integrating clinical evidence-based guidelines and care management systems across continuum of care.
    The Director will also be responsible for developing the systems and processes to achieve results in support of the Quadruple Aim: Quality, Cost, Experience and Satisfaction.

    Responsibilities: - Provides overall direction, design, development implementation and monitoring of utilization programs to meet the Hospital's utilization goals while maintaining customer satisfaction
  • Acts as a resource to the medical staff, administrative staff, divisional, and external regulatory agencies in all issues relating to utilization management

  • Oversees outside medical services based on Health Plan benefit guidelines and medical necessity

  • Analyzes and reports significant utilization trends, patterns, and impact to appropriate departmental and medical staff committees

  • May direct the operations of outside referrals/transportation services

    Requirements:
    - BSN or bachelor's degree in health care related field such as management, health services administration
  • Illinois RN License required

  • Three to five years' experience in Population Health Management

  • Demonstrated knowledge of operations and healthcare management; TJC, Title XXII, Medicare, Medi-Cal and other local, state and federal regulations

  • Knowledge of managed care operations

  • Demonstrated interpersonal, negotiation, and leadership skills

  • Effective oral and written communication skills

  • Must be able to work in a Labor/Management Partnership environment For all of our Case Management opportunities, please forward a resume to Otie Pruett at or visit our Case Management website at If this opportunity is of interest, please feel free to contact me at your earliest convenience.
    If there is someone that you know who may be interested in this opportunity, I would appreciate the referral.
    Thanks!
    Otie Pruett VP of Case Management Recruitment Email: Direct:

See if you are a match!

See how well your resume matches up to this job - upload your resume now.

Find your dream job anywhere
with the LiveCareer app.
Download the
LiveCareer app and find
your dream job anywhere
lc_ad

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
RN Medical Case Manager Workers Compensation

The Travelers Companies

Posted 2 weeks ago

VIEW JOBS 10/30/2018 12:00:00 AM 2019-01-28T00:00 Primary Job Duties & Responsibilities Contact customer, medical provider and injured parties on claims involving medical treatment and /or disability to coordinate appropriate medical care and return to work. Develop strategies to facilitate an injured employee's return to work and achieve maximum medical improvement. Evaluate and update treatment and return to work plans within established protocols throughout the life of the claim. Coordinate with medical providers to ensure the injured employee is actively participating in a viable treatment plan. Evaluate medical treatment requests to ensure that they are reasonable and necessary based upon jurisdictional guidelines. Engage specialty resources as needed to achieve optimal resolution (Dial-a-doc, physician advisor, peer reviews, MCU). Partner with Claim Professional to provide medical information and disability status necessary to create an overall strategy to achieve an optimal outcome. Utilize internal Claim Platform Systems to manage all claim activities on a timely basis. Utilize Preferred Provider Network per jurisdictional guidelines. Partner with Claim Professional to provide input on medical treatment and recovery time to assist in evaluating appropriate claim reserves. Submit accurate billing documentation on all activities as outlined in established guidelines. Customer Engagement. Participate in Telephonic and/or onsite File Reviews. Respond to inquiries - oral and written. Keep injured worker apprised of claim status. In-person medical case management may be required to support Concierge locations, where a Nurse Case Manager meets with injured employees face to face following office visits at a provider's medical facility. In order to perform the essential functions of this job, acquisition and maintenance of Insurance License(s) may be required to comply with state and Travelers requirements. Generally, license(s) must be obtained within three months of starting the job and obtain ongoing continuing education credits as mandated. Job Specific & Technical Skills & Competencies Familiarity with URAC standards Analytical Thinking: Identifies current or future problems or opportunities; analyzes, synthesizes and compares information to understand issues; identifies cause/effect relationships; and explores alternative solutions that support sound decision-making. Communication: Expresses, summarizes and records thoughts clearly and concisely orally and in writing by applying proper content, format, sentence structure, grammar, language and terminology. Ability to effectively present file resolution to internal and/or external stakeholders. Negotiation: Intermediate ability to understand alternatives, influence stakeholders and reach a fair agreement through discussion and compromise. General Insurance Contract Knowledge: Ability to understand policies and contracts, as they apply to policy conditions. Principles of Investigation: Intermediate investigative skills. Follows a logical sequence of inquiry with a goal of securing information about the work accident, resulting injury, anticipated treatment, job duties and any material factors that may impact recovery and return to work. Value Determination: Basic ability to determine liability and assigns a dollar value based on damages claimed and estimates, sets and readjusts reserves. Legal Knowledge: Basic knowledge, understanding and application of state, federal and regulatory laws and statutes, rules of evidence, chain of custody, trial preparation and discovery, court proceedings, and other rules and regulations applicable to the insurance industry. Medical knowledge: Thorough knowledge of the nature and extent of injuries, periods of disability, and treatment needed. WC Technical: intermediate ability to demonstrate understanding of WC Products and ability to apply available resources and technology to manage treatment plans and assist with claim resolution. Demonstrate a clear understanding and ability to work within jurisdictional parameters within their assigned state. Customer Service: Advanced ability to build and maintain productive relationships with our insureds and deliver results with optimal outcomes. Teamwork: Advanced ability to work together in situations when actions are interdependent and a team is mutually responsible to produce a result. Planning & Organizing: Advanced ability to establish a plan/course of action and contingencies for self or others to meet current or future goals. Job Summary Under moderate supervision, provide office based telephonic medical case management with emphasis on early intervention, return to work planning, coordination of quality medical care on claims involving disability and medical treatment as well as in-house medical reviews as applicable to claim handling laws and regulations. Responsible for helping to ensure injured parties receive appropriate treatment directly related to the compensable injury or assist claim handlers in managing medical treatment to an appropriate resolution. This job does not manage others This job works under Moderate Supervision: Incumbent performs standard and routine assignments independently to conclusion; unusual problems which may require exceptions to procedures or processes are referred to the supervisor. As part of the hiring process, this position requires the completion of an online pre-employment assessment. Further information regarding the assessment including an accommodation process, if needed, will be provided at such time as your candidacy is deemed appropriate for further consideration. Education, Work Experience & Knowledge Disability case management experience preferred. Prior clinical experience preferred. Bilingual preferred. Physical Requirements Operates standard office equipment (Continuously) Sitting (can stand at will) (Continuously) Use of Keyboards, Sporadic 10-Key (Continuously) Driving (Occasionally) Minimum Qualifications Registered Nurse; Licensed Practical Nurse or Licensed Vocational Nurse required. The Travelers Companies Naperville IL

RN Director Of Care And Utilization Management

The Clinical Recruiter