DIRECTOR - UTILIZATION MANAGEMENT

Palo Verde Behavioral Health - Tucson, AZ (30+ days ago)4.4


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Palo Verde Behavioral Health (PVBH) is a 84 bed private psychiatric facility providing inpatient and intensive outpatient psychiatric services through treatment programs tailored to our patients needs for the purpose of creating positive outcomes. PVBH will build on the excellent skills of our current Psychiatrists, licensed registered nurses, clinical social workers and licensed professional counselors to support these programs.

Mission Statement

The mission of Palo Verde Behavioral Health is to provide the highest quality of psychiatric patient care through treatment programs focused on improving the lives of our patients and ensuring their experience during their stay supports their road to recovery.

Vision Statement

Palo Verde Behavioral Health will be recognized as the premier regional provider of innovative, compassionate behavioral health services, which enhance the health of our community. We will exceed the expectations of those served, maintain the highest standards, and promote a rewarding work environment.

JOB DESCRIPTION:
The Director of Utilization Management is responsible for directing and overseeing the Utilization Management Program for inpatient. This includes the implementation of case management scenarios, consulting with all services to ensure the provision of an effective treatment plan for all patients, oversees the response to requests for services and interfaces with managed care organizations, external reviewers, and other payers.
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JOB REQUIREMENTS:
To perform this job successfully, an individual must be able to demonstrate competency in the criteria listed in this job description. The specifications listed below are representative of the knowledge, skill, and ability to meet the minimum requirements for this position. Staff must demonstrate knowledge and skill in provision of services to various populations including children, adolescents, adults, older adults and dually diagnosed patients in an inpatient and partial hospital setting.

Education: Degree in nursing, social work, mental health/behavioral sciences, or related field preferred. Combination of education and experience may be considered.

Experience: A minimum of five (5) years direct clinical experience in a psychiatric or mental health treatment setting. A minimum of one year of managing a related function is preferred. Experience in patient assessment, family motivation, treatment planning and communication with external review organizations or comparable entities.

Licensure/Certification: LMSW, LPC, RN or LVN is required.

SKILLS:
1. Knowledge of external review organization (i.e. managed care, Medicare, Medicaid).

2. Knowledge of patients’ rights, advanced directives, adult and child abuse laws, and emergency detention.

3. Working knowledge of payer resources and financial planning.

4. Demonstrate willingness to acquire knowledge and expertise in complex patient care planning.

5. Skill in organizing and prioritizing workloads to meet deadlines.

6. Skill in telephone etiquette and paging procedures.

7. Effective oral and written communication skills.

8. Excellent leadership and negotiation skills.

9. Excellent customer relations skills.

10. Ability to manage conflicting situations.

11. 11. Ability to be relationship focused by interacting with multiple individuals with diversified roles and perspectives.

12. 12. Ability to operate in an unstructured environment, orchestrate a myriad of activities and to manage multiple priorities within complex systems.

13. Ability to tolerate ambiguity, uncertainty and change.

14. Ability to work at a rapid pace.

15. 15. Ability to manage and plan one’s own schedule with calls, assessment fluctuations and demands as required.

16. Ability to communicate effectively with patients and co-workers.

17. Ability to adhere to safety policies and procedures.

18. Ability to use good judgement and to maintain confidentiality of information.

19. Ability to work as a team player.

20. Ability to demonstrate tact, resourcefulness, patience and dedication.

21. Ability to accept direction and adhere to policies and procedures.

22. 22. Ability to recognize the importance of adapting to the various patient age groups (adolescent, adult and geriatric).

23. Ability to work in a fast-paced environment.

24. Ability to meet corporate deadlines.

25. Ability to react calmly and effectively in emergency situations.

SUPERVISION EXERCISED: Utilization Review & Discharge Planning

SUPERVISION RECEIVED: C.F.O

CLASSIFICATION: Exempt

GENERAL WORKING ENVIRONMENT: Work in general office environment and hospital units/programs. Exposure to psychiatric patients’, who may exhibit violent/aggressive behavior. Potential for exposure to communicable diseases, blood/body fluids and other hazardous waste. General hospital environment.

PHYSICAL REQUIREMENTS:
1. Ability stand, or walk up to six hours.

2. Ability to stand up to two hours.

3. 3. Ability to spend 20% of the work day outdoors in temperatures varying from -30 F. to 100F. and 80% of the wok day indoors in temperatures varying from 60F. to 85F.

4. 4. Ability to occasionally push/pull wheeled carts from 200 pounds (i.e. crash carts, patients on stretchers or in wheelchairs).

5. 5. Ability to frequently lift and carry up to 10 pounds (charts, records); occasionally lift and carry up to 100 pounds.

6. Ability to see well enough to read written material and 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 for cleaning; where mechanical and electrical hazards may be present; and where dust, mist and steam are frequently generated in housekeeping tasks.

MACHINES, TOOLS, EQUIPMENT, AND OTHER WORK AIDES:
1. Computer and software programs.

2. Telephone and paging systems.

3. Fax machine.

4. Calculator/10-key.

5. Copy machine.

6. Medical records.

7. Policies, procedures, plans and program manuals.

JOB SPECIFICATIONS: To perform this job successfully, an individual must be able to perform each primary duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/ or ability required. Reasonable accommodations may be made to enable individuals with disabilities, who are otherwise qualified, to perform the primary functions.

Program Planning and Treatment

1. 1. Review the effectiveness of the comprehensive interface with external reviewers, communicate with external reviewers and managed care organizations to assure timely and appropriate interactions, monitor outcomes of reviews and provide consultation as needed.

2. Review the quality of documentation provided at all levels of care to assure adequacy and clinical appropriateness.

3. Assure patients are receiving effective and appropriate treatment, based on the level of care.

4. 4. Establish standards for customer relations and monitor the interactions between Utilization Management staff and customers to evaluate the effectiveness of customer service.

5. 5. Direct the program services offered, consulting with facility management in the planning, development, implementation and evaluation of the Utilization Management program.

6. Maintain current awareness of mental health activities in the community.

7. 7. Maintain an awareness of community and market-related activities which includes knowledge of the activities of other providers, needs of local payers and the political climate related to mental health.

8. Participate in clinical team analysis and evaluation of current services offered at the facility.

9. 9. Strategically solve problems that encompass the larger view of the organization, and establish goals by utilizing an understanding of organizational dynamics in planning and problem solving.

10. Remain current on all clinical techniques, and provide direction to staff and facility personnel.

11. 11. Participate in developing, justifying and controlling the annual budget for department personnel, facilities and equipment.

12. Ensure strategic program goals and objectives are consistent with overall facility goals and objectives.

13. Develop goals and objectives, policies and procedures related to the operational needs of the programs scenarios.

14. 14. Consult with facility management in the development and facilitation of program activities which assure an optimal therapeutic experience for all patients

15. 15. Participate with ensuring that individual patients and their families are involved in the development of individualized treatment plans.

16. Maintain an active involvement and awareness of all patient admissions, discharges and transfers.

17. 17. Meet regularly with program managers and the Medical Director and program staff to ensure compliance with program goals and objectives.

18. Serve on Facility Committees and attend meetings as assigned.

19. Provide services to current referral sources to assure their satisfaction and continued associations.

20. Develop and maintain a system to minimize and address denials in consult with the facility Director of Operations, Business Office Manager, CEO and CFO.

Personnel Management and Staffing

1. Maintain and allocate a well-qualified core of staff resources.

2. Assure that hiring, disciplinary actions and termination procedures are conducted in accordance with hospital policies.

3. 3. Involve appropriate facility management in all decisions, and review these decisions with COO prior to implementation.

4. 4. Assure adequate supervision and evaluation processes for all staff members and delegate these responsibilities as appropriate.

5. Assure adequate orientation for new employees of the Utilization Review Department.

6. Provide for educational needs and professional development of staff.

7. Ensure that the staff schedule and configuration will meet the needs and demands of the patient population and census and adjust it accordingly.

8. Ensure an adequate system of communication and reporting is maintained between all staff members, as well as other departments involved in the ongoing operation of the program.

9. Create a structure that best meets the needs of the organization, particularly department organization related to supervision and assignment of staff.

10. Routinely review job assignments and utilization of staff.

Clinical Leadership

1. Conduct department meetings on a regular basis.

2. 2. Work with clinical leadership to ensure interdisciplinary treatment planning is organized with participation of all appropriate clinical disciplines.

3. Ensure all patient, family and referral complaints are promptly handled.

4. Coordinate the collection of outcome data within the company deadline.

Continuous Quality Improvement

1. Ensure that a system is developed to provide continuity of care and communication with family and appropriate referral sources, and ensure the system is evaluated and reviewed regularly.

Daily reporting of denials to CFO.

3. Ensure the department meets Joint Commission, Medicare and federal and state regulatory requirements.

4. Develop and implement a Performance Improvement tracking system, evaluate the results quarterly, and report results to the Performance Improvement Committee in a timely manner.

5. Ensure that all deficiencies identified through the performance improvement analysis are addressed with appropriate problem solving actions.

6. Review all department risk management occurrence and ensure that complete and timely reports are submitted to Risk Management.

Analyze statistical data of the program to determine and respond to trends.

Additional Standards

1. Implement planning and teaching staff documentation training.

2. Serves on Facility Committees as assigned.

3. Accepts responsibility for professional growth and development.

4. Demonstrates a professional attitude and supports the objectives of the Facility philosophy through internal and external communications and interactions with all levels of staff, patients, family members, guests, community, and referral sources.

5. Adhere to facility, department, corporate, personnel and standard policies and procedures.

6. Attend all mandatory facility in-services and staff development activities as scheduled.

7. Adhere to facility standards concerning conduct, dress, attendance and punctuality.

8. Support facility-wide quality/performance improvement goals and objectives.

9. Maintain confidentiality of facility employees and patient information

Note: The essential job functions of this position are not limited to the duties listed above.

SERVICE EXCELLENCE CRITERIA:
Treats everyone as a guest.
Makes a positive first impression and continues that positive impression through ongoing efforts
Anticipates the needs and expectations of all people encountered
Displays service recovery skills; is responsible for resolving dissatisfaction without assigning blame

Demonstrates professionalism and excellence in all things.
Demonstrates professionalism in look, what to do, and what to say

self accountable – Is a positive role model

excellence that goes beyond departmental and individual job responsibility

Practices teamwork
Participates in decision-making and process improvement, regardless of level in the organization

effectively within and beyond assigned team

on the problem or issue, not the person

Behaviors: Always says “please” and “thank you”. Makes a good first impression by projecting a positive attitude; greets patients, guests and staff warmly.
Behaviors: Always wears name badge. Demonstrates a professional image through manner of dress, respectful communication, and adherence to hospital badge policy.
Behaviors: Holds self accountable for getting the information needed to know to do job. Responds to client and customer questions, concerns and grievances in a timely manner, informing complainant of process and expected time of resolution.
Behaviors: Uses language appropriate to the situation and to the guest. Is a team player, showing respect for peers, supervisors, patients and guests, demonstrated through verbal communications and commitment to the work group.
Behaviors: Greet guests with eye contact and a smile. Staff is timely when responding to patient needs and requests by making eye contact and verbal contact when patient presents self at nurse’s station or any other area where staff is located.
Behaviors: Always end an interaction with the guest by asking, “Is there anything else I can do for you?” Provides service to patients and families that is prompt, caring, efficient and effective.
Demonstrates respect for the hospital environment by keeping work areas organized and clean, and taking pride in the facility as a whole.

GENERAL CRITERIA

Attendance: Consistently reports to work on time and is ready to work at start of shift. Appropriately utilizes personal days/sick time. Clocks in/out per policy and procedure; begins/returns from meal periods and rest breaks within established policy time frame.
General Safety: Follows all departmental and hospital safety, security and infection control policies.
Self-Development: Maintains required licensure/certification for position; renews by expiration date; Maintains MANDT training; renews by expiration date. Gains additional formal qualifications beyond the minimum requirements of the job; as well as additional job duties and skills. Follows up on any personal development plan. Maintains current knowledge of policies and procedures, protocols, and practices. Attends inservice programs.
Professional Appearance and Attitude: Complies with the Personal Appearance policy. Consistently demonstrates a self-directed, mature and disciplined approach to completing work duties. Demonstrates emotional capacity to perform within position responsibilities. Maintains and respects patient and employee confidentiality. Follows proper lines of authority and organizational structure.

The Following is the minimum knowledge, skills and behaviors necessary to provide care and service for the patient population served:

AGE GROUP ENCOUNTERED :  Adolescent – (13-17 yr. old)

 Adult – (18 - 54 yr. old)  Geriatric – (55 or above)

Must be able to demonstrate knowledge of patient rights, advanced directives and ethical issues for all age specific groups.

be able to demonstrate the skills and knowledge to provide appropriate interventions based on the needs of various age groups.

be able to demonstrate knowledge and ability to advocate, communicate and educate patients of all age groups served, including those with physical, emotional, social, mental, language and cognitive impairments.

be able to demonstrate knowledge and ability to collaborate with medical staff, other health professionals to achieve desired outcomes for age specific groups served.

be able to demonstrate knowledge and skills to interpret age related data and appropriately consulting with other team members and/or planning care based on those results.

be able to demonstrate ability to provide patient/family education, explaining care, treatments, discharges instruction etc. using correct terminology and technique to address educational needs of each age group served.

be able to demonstrate knowledge and ability to assess and provide appropriate interventions in the event of abnormal family dynamics for various age groups including; child abuse, domestic violence, and elder abuse.

be able to demonstrate knowledge and ability to provide a safe environment of care and recognize safety risks/considerations of each age group served.

be able to demonstrate proper application and knowledge of policies and procedures related to restraint alternatives and usage for various ages of patients served.

be able to demonstrate knowledge of the principles of growth & development of the life-span.

be able to modify and deliver care that is specific to the age and growth & development of the patient served.

be able to demonstrate knowledge and ability to provide structured educational groups.