JOB DESCRIPTION FOR JOB TITLE:



|POSITION SPECIFICS |

|Title: Program Manager, Medicare/MA Utilization Review (UR) |Department/Number: Coordinated Care/93070 |

|Reports to: Director, Coordinated Care |PD Status: Approved |

|Job Code: 2464 |FLSA Status: Exempt |Bargaining Unit: NA | |

|Manager Approval:     Date:       |HR Approval: DPS 2-14 |

|POSITION SUMMARY |

|The Program Manager is responsible for designing and managing the implementation, operations, and evaluation of processes and functions within the |

|Medicare/Medicare (MA) Utilization Review (UR) Program. This individual has well developed knowledge and skills in areas of Utilization Management (UM), |

|Medical Necessity, and Patient Status determination. Responsibilities include supporting the UM Program by ensuring there is accurate and concurrent analysis |

|of Medicare and Medicaid patient clinical records to determine accuracy of admission, treatment, and length of stay for the purpose of complying with |

|governmental, reimbursement and regulatory requirements. Responsibilities include developing communication messages for both internal/external stakeholders, |

|creating/coordinating reports, statistics and analysis of data in order to track and trend for the purpose of improving programmatic performance. The Program |

|Manager analyzes and researches best practice programs and drafts business plans/proposals as needed. |

| |

|The Medicare/MA Utilization Review Program Manager is considered a technical expert in the field of utilization management and ensures all within the |

|department have current and accurate knowledge of state and federal UM requirements for the purpose of assuring compliance with reimbursement and regulatory |

|requirements. This individual also maintains current knowledge of UM trends and requirements for non-governmental/commercial payers for the purpose of giving |

|direction and support to UM practices across UW Hospital and Clinics. This Program Manager identifies and implements opportunities for improvement in the area|

|of Medicare/MA Utilization Review by developing, providing structure for additional orientation, training and competency development for appropriate staff and |

|colleagues on an ongoing basis. Activities associated with the Medicare/MA program management role have organizational, local, regional, state, and national |

|wide impact. Additionally, the Medicare/MA Utilization Review Program Manager is responsible for directing, evaluating, and providing feedback to professional |

|level employees who participate in the operations of the Utilization Management Program. This Program Manager will direct the work of other employees, |

|occasionally from multiple cost centers and is responsible for communication of any programmatic or resource needs across multiple departments. |

| |

|This individual reports directly to the University of Wisconsin Hospital and Clinics Director of Coordinated Care and is in direct collaboration with the |

|Utilization Review Physician Advisors and the Department of Coordinated Care Outcome Managers. This individual also collaborates closely with leadership staff |

|from Admissions, Fiscal, Coding, Compliance, Legal, Internal Audit and other Directors across the organization for the purpose of improving clinical, |

|operational, and financial outcomes. |

|MAJOR RESPONSIBILITIES |

| |

|Program Leadership |

|Design, implement and evaluate utilization management functions specific to the Medicare/Medicaid UM Program. |

|Ensure that case management staff is appropriately managing patient admission status. |

|Serve as a technical expert and resource for the Department of Coordinated Care to assist in determining admission status and documentation standards. |

|Assure that hospital short stay patients are appropriately reviewed. Supervise the post-discharge review and all work functions of the Medicare/Medicaid UR |

|Nurse Coordinator. Provide performance feedback to appropriate managers for employees performing Medicare/Medicaid UM activities. |

|Develop and maintain management information systems to support analysis and reporting on UM functions and systems. |

|Develop data and report to various audiences including the hospital’s UR Committee. Provide interpretation and analysis of UM-related data. |

|Prepare discussion and appeal letters for Medicare and Medicaid medical necessity denials. |

|Review and analyze current audit information for the purpose of education and development of Case Manager and Outcome Manager staff. |

|Collaborate and lead discussions specific to Medicare/Medicaid audit activities with the RAC committee. |

|Interpret state and federal regulations and government contractor statements of work and provide recommendations for department and hospital compliance. |

| |

|Service Delivery |

|Provide clinical consultation on utilization management issues and trends to physicians and other |

|UW Health colleagues within the UW Health System. |

|Respond to all internal and external requests for information, data, and/or education specific to Utilization Management. |

|Seek consultation from appropriate disciplines/departments as required to expedite UM processes. |

|Refer patient utilization management issues to the Director of Coordinated Care, Physician Advisor or Outcome Manager in a timely manner, as indicated. |

| |

|Collaborate with Nursing, Physicians, Admissions, Fiscal, Coding, Compliance, Legal and Internal Audit staff to answer clinical questions specific to medical |

|necessity and patient status. Delegate these requests to appropriate staff as needed. |

|Co-lead the hospital’s UR Committee in conjunction with the Director of coordinated Care and the Physician Advisors. |

|Provide oversight and monitor completion/distribution of the IM (Important Message) prior to the patient’s discharge. |

|Provide consultation and assistance with issuance of the hospital notice of non-coverage (HINN) and the Discharge Notice of Non-Coverage letters to patients |

|when needed. |

|Oversee strategic and operational projects as it relates to the Medicare/Medicaid UM program. |

|Participates in providing education related to functions of the Medicare/Medicaid UM program. |

|Role models service excellence in interactions with internal and external constituents. |

|Establishes strong cooperative relationships with applicable leaders by providing the information, tools and services necessary to improve the outcomes |

|associated with the Medicare/Medicaid UM Program. |

| |

|Communication |

|Design and orchestrate the delivery of applicable communication to internal and external constituents. |

|Demonstrates excellent oral and written communication using a variety of methodologies. |

|Coordinates presentations and ensures consistent communication related to the Medicare/Medicaid UM Program. |

|Translate data and information into meaningful stories related to strategic aspects of the Medicare/Medicaid UM Program. |

| |

|Operational Improvement |

|Oversee collection and utilization of operational and benchmarking data to recommend and set targets for improvements. |

|Prepare appropriate reports, statistics and conduct surveys in order to evaluate departmental operational and fiscal performance. |

|Participate in the review of program and workflow processes. Recommend and participate in implementation of process improvements. Monitor and measures process|

|changes. |

|Facilitate cross-functional performance improvement teams. |

|Research industry best practices and recommend process improvements to leadership. |

|Develop, review and recommend policies that support the direction of the Medicare/Medicaid UM program. |

| |

|Strategic Planning |

|Program leader for Medicare/Medicaid UM activities who works collaboratively with appropriate stakeholders to plan for ongoing development and growth in the |

|Medicare/Medicaid UM Program. |

|Establish monitoring process for tracking performance of new programs to facilitate programmatic adjustments needed to assure accomplishment of goals. |

|Research and synthesize operational and benchmarking best practices, prepare reports, proposals and business plans as indicated. |

|Develop processes to assure timely communications to stakeholders about the status of projects being planned or implemented. |

| |

|Recognition |

|Research, analyze, and recommend opportunities for external recognition. |

|Manage the process and completes applications for external recognition. |

|Coordinate content for external recognition applications with operational leaders throughout UWHC. |

| |

|Research |

|Be involved in research projects, analysis, and distribution of findings. Facilitate protocol design for accurate data collection, feedback, and analysis. |

| |

|Miscellaneous |

|Responsible for other miscellaneous duties as assigned. |

| |

|All duties and requirements must be performed consistent with the UWHC Organizational Performance Standards. |

|POSITION REQUIREMENTS |

|Education |Minimum |Master's Degree in Nursing or Related Field |

| |Preferred |Master’s Degree in Nursing |

|Work Experience |Minimum |Five (5) years experience working within case management or utilization management with at least one (1) year that |

| | |includes program management or program development in this setting. |

| |Preferred | |

|Licenses & |Minimum |Licensed as a Registered Nurse in the State of Wisconsin or equivalency. |

|Certifications | |Certification in area of specialty or eligible for certification. |

| |Preferred | |

|Required Skills, Knowledge, and |Exceptional oral/written communication skills. |

|Abilities |Ability to independently research issues and make effective recommendations using critical thinking skills. |

| |Effective analytical ability to solve complex problems and issues. |

| |Excellent customer service skills and ability to work with a diverse group of people. |

| |Track record demonstrating ability to function independently and as a team member, and consistently deliver quality |

| |outcomes. |

| |General knowledge of the principles and practices of human resource management. |

| |Excellent organizational skills and attention to detail. |

| |Competent in MS Outlook, Word, Excel, and PowerPoint. |

|AGE – SPECIFIC COMPETENCY |

|Identify age-specific competencies for direct and indirect patient care providers who regularly assess, manage and treat patients. |

|Instructions: Indicate the age groups of patients served either by direct or indirect patient care by checking the appropriate boxes below. Next, |

| |Infants (Birth – 11 months) | |Adolescent (13 – 19 years) |

| |Toddlers (1 – 3 years) |X |Young Adult (20 – 40 years) |

| |Preschool (4 – 5 years) |X |Middle Adult (41 – 65 years) |

| |School Age (6 – 12 years) |X |Older Adult (Over 65 years) |

|Job Function |

|Review the employee’s job description, and identify each essential function that is performed differently based on the age group of the patient. |

| |

|PHYSICAL REQUIREMENTS |

|Indicate the appropriate physical requirements of this job in the course of a shift. Note: reasonable accommodations may be made available for individuals |

|with disabilities to perform the essential functions of this position. |

|Physical Demand Level |Occasional |Frequent |Constant |

| |Up to 33% of the time |34%-66% of the time |67%-100% of the time |

|X |Sedentary: Ability to lift up to 10 pounds maximum|Up to 10# |Negligible |Negligible |

| |and occasionally lifting and/or carrying such | | | |

| |articles as dockets, ledgers and small tools. | | | |

| |Although a sedentary job is defined as one, which | | | |

| |involves sitting, a certain amount of walking and | | | |

| |standing is often necessary in carrying out job | | | |

| |duties. Jobs are sedentary if walking and | | | |

| |standing are required only occasionally and other | | | |

| |sedentary criteria are met. | | | |

|List any other physical requirements or bona fide | |

|occupational qualifications: | |

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