Reference #: 1009367 SHIFT:Day (United States of America)

Seeking Breakthrough Makers

Children's Hospital of Philadelphia (CHOP) offers countless ways to change lives. Our diverse community of more than 20,000 Breakthrough Makers will inspire you to pursue passions, develop expertise, and drive innovation.

At CHOP, your experience is valued; your voice is heard; and your contributions make a difference for patients and families. Join us as we build on our promise to advance pediatric care-and your career.

CHOP's Commitment to Diversity, Equity, and Inclusion

CHOP is committed to building an inclusive culture where employees feel a sense of belonging, connection, and community within their workplace. We are a team dedicated to fostering an environment that allows for all to be their authentic selves. We are focused on attracting, cultivating, and retaining diverse talent who can help us deliver on our mission to be a world leader in the advancement of healthcare for children.

We strongly encourage all candidates of diverse backgrounds and lived experiences to apply.

A Brief Overview This will be a hybrid role as UM supervisor with 2 days onsite. Will be reporting to the UM manager and will pair with the manager to lead the UM team. The team is looking for an energetic leader who is flexible and excited to learn new things. Previous UM and appeals expereince preferred This does require a BSN, 3 years RN experience in an acute setting as well as 5 years hospital or healthcare leader expereince. Under the direction of the Manager, Utilization Management, the Supervisor Utilization Review (UR) oversees the development, implementation, and performance management of the Utilization Review and Denials Prevention program across all Children's Hospital of Philadelphia (CHOP) acute hospitals. This pivotal role entails managing utilization review and authorization management services to promote appropriate levels of care, length of stay, and prevention of payer denials.

The supervisor consistently demonstrates the ICARE values of CHOP and serves as a role model to other employees.

What you will do 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 pr posals. 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.

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

Experience Qualifications 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

Skills and Abilities 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.

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

To carry out its mission, CHOP is committed to supporting the health of our patients, families, workforce, and global community. As a condition of employment, CHOP employees who work in patient care buildings or who have patient facing responsibilities must be fully vaccinated against COVID-19 and receive an annual influenza vaccine.

Employees may request exemptions for valid religious and medical reasons. Start dates may be delayed until candidates are immunized or exemption requests are reviewed.

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Children's Hospital of Philadelphia is an equal opportunity employer. We do not discriminate on the basis of race, color, gender, gender identity, sex