JOB SUMMARY: Provides utilization management and systems review activities for “For My Baby & Me”. Work collaboratively with agency partners and community stakeholders and makes recommendations on protocols and systems to support optimum program/grant outcomes.
Essential Functions
- Oversee evaluation activities including the development of effective data collection, monitoring and reporting in compliance with applicable grants (For My Baby and Me).
- Utilizes best practice standards to render medical necessity determinations.
- Analyze, evaluate and measure project outcomes and incorporate results into sustainability and strategic evaluation planning.
- Write process and outcomes reports including quarterly performance assessments including protocol recommendations.
- Provides case consultations for complex cases and situations.
- Collaborates with interdisciplinary teams to assess physical, behavioral, social and transitional care needs and assists as needed to develop person‑centered, integrated, recovery-oriented service plans to meet the needs of the consumer.
- Monitors staff for appropriateness and congruence of application of medical necessity criteria during utilization review process. Provides training to staff as needed.
- Assists in the recommendation of client/consumers care to designated collaborating agencies and monitors care and length of stay.
- Recognizes quality of care issues and reports them appropriately through internal/external processes under the direction of the Nurse Executive/Director of Nursing.
- Implements valid and reliable monitoring tools to conduct both quantitative and qualitative analysis of consumer care/quality measures in accordance with acceptable statistical and quality improvement processes/systems.
- Manages, monitors, and reports on both concurrent and retrospective review of consumer records to ensure consumers received/are receiving the right care, in a timely and cost-effective manner and recommends solutions to improving the efficiency and effectiveness of service delivery via program administration and/or the quality improvement process.
- Provide linkages, referrals, and coordination of care.
- Other duties as assigned by nurse executive/director of nursing.
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