Registered Nurse-Supervisor for Utilization Management

• Essential Duties and Responsibilities:
• Supervision and Leadership: Lead and manage the utilization management team, including recruitment, training, performance management, and coaching to ensure optimal team performance and productivity.
• Utilization Review: Oversee the utilization review process, including evaluating medical necessity, appropriateness of care, and compliance with clinical guidelines and policies.
• Quality Assurance: Monitor and evaluate the quality and accuracy of utilization management decisions, ensuring compliance with regulatory requirements and accreditation standards.
• Process Improvement: Identify opportunities for process improvement and implement strategies to streamline workflows, enhance efficiency, and optimize utilization management practices.
• Collaboration: Collaborate with internal stakeholders, including healthcare providers, care managers, and other departments, to facilitate effective communication and coordination of care.
• Data Analysis: Analyze utilization data, trends, and outcomes to identify areas for improvement and support decision-making processes.
• Compliance: Ensure compliance with relevant laws, regulations, and accreditation standards governing utilization management activities.
• Training and Education: Develop and deliver training programs and educational materials to support staff development and ensure understanding of utilization management principles and practices.
• Alignment with hospital leadership teams and consistently demonstrates ability to:
• Develop strategies to manage and prevent disputes and improve Revenue Cycle processes with Revenue Cycle Directors and managers.
• Build trusting relationships with hospital leaders to successfully implement new programs.
• Build collaborative partnerships and lead cross functional teams to execute on plans and proposals.
• Identify process inefficiencies via root cause analysis and design work flow to address opportunities identified
• Develop and implement action plans managing follow-up to achieve outcomes.
• Implement targeted process changes including ongoing metric monitoring and management to achieve goals and drive improvement.
• Other Responsibilities:
• Adheres to established departmental policies, procedures, and objectives.
• Enhances professional growth and development by accessing educational programs, job related literature, in-service meetings, and workshops/seminars.
• Maintains established department/hospital/system policies and procedures, directives, safety, environmental and infection control standards appropriate to this position.
• Demonstrates a courteous and professional manner through interactions with internal and external customers.
• Integrates scientific principles and research based knowledge in decision making.
• Exemplifies a professional image in appearance, manner and presentation.
• Engages in self-performance appraisal, identifying areas of strength as well as areas for professional development.
• Researches, selects and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes.
• Performs other related duties as assigned.

• Bachelor's Degree Business, Nursing, or Health Care Administration Required
• Master's Degree Business, Nursing, or Health Care Administration Preferred

• At least three (3) years experience as a clinical nurse in an acute care setting. Required
• At least five (5) years hospital or healthcare leadership Required
• At least three (3) years Case Manager or Utilization Reviewer Preferred
• At least three (3) years Case Management Leadership role Preferred

• Excellent communication skills and demonstrated organizational skills.
• Knowledge of payor contracts and regulatory requirements.
• Ability to work effectively with all departments and all levels of CHOP professionals.
• Ability to work independently or within a team structure.
• Must be very organized and able to work independently.
• Ability to establish priorities among multiple needs, meet deadlines and maintain productivity standards.
• Knowledge of managed care admission process (i.e. verification of benefits, admissions notification).
• Ability to effectively negotiate with internal and external providers of patient care services.
• Sound problem-solving and analytical skills.
• Excellent customer service orientation and strong interpersonal skills.
• Computer skills and a working knowledge of Word, Excel and PowerPoint.

• Registered Nurse (Pennsylvania) - Pennsylvania State Licensing Board - upon hire - Required
• Certified Case Manager (CCM) - Commission for Case Manager Certification - upon hire - Preferred

Children’s Hospital of Philadelphia