• Utilization Review Supervisor

    Job Location(s) US-Any
    Job ID
    # of Openings
    Case Management
    Job Type
    Regular Full-Time
  • Overview

    Position Summary:

    The Supervisor is responsible for the overall supervision of their assigned team. The Supervisor participates in administering company best practices to meet department goals and objectives. This position will require current knowledge of evidence based nursing and the ability to demonstrate critical thinking skills in the implementation of all phases of the nursing process.


    Essential Duties and Responsibilities:


    Possess excellent communication and organizational skills to interface with the client, claimants and staff. Work well independently and set priorities and work independently is essential.

    Primary responsibilities include:

    • Represents the company in a professional manner to both internal and external customers and clients.
    • Assures performance standards of the team through continued training and coaching, quality assurance along with regular performance evaluations.
    • Responsibilities include providing clinical, technical and operational support and direction, including organization and monitoring of utilization review services
    • Assists with the daily operations of licensed and non-licensed professionals
    • Monitors staff work assignments and makes appropriate adjustments based on staffing levels
    • Provides coaching and training to improve productivity of staff members within team.
    • Accurately answers questions regarding Utilization Review for clients, injured workers and providers.
    • Assists in training of new staff and ongoing training to ensure staff’s expertise.
    • Reviews quality audits and shares audit results in a timely manner with associates, providing necessary education and training to improve performance.
    • Works collaboratively with the Manager and identified leadership to develop and implement performance measures, and monitors associates placed on performance improvement plans.
    • Responsible for completing annual reviews for direct reports with Manager input.
    • Creates and supports an environment that fosters teamwork, cooperation, respect, and diversity.
    • Ensures staff compliance with URAC and Utilization Review requirements and mandated regulatory requirements
    • Utilizes jurisdictional knowledge of regulatory rules, statutes and procedures governing the jurisdictions assigned to ensure compliance.
    • Quality Assurance meetings 20% of total time is designated for Quality Assurance
    • Assists in developing and overseeing the implementation of utilization review practices and procedures with assigned team members
    • Ensures consistent and complete compliance with TRISTAR’s policies and procedures.
    • Maintains communication among staff members in the department and communicates with management team.
    • Participation in management team and supervisory meetings
    • Client Stewardship


    Additional Functions and Responsibilities

    • Excellent written and verbal communication skills necessary for staff and client contact, presentations, and personnel management.
    • Excellent leadership skills, with a demonstrated ability to motivate staff and obtain results through teamwork.
    • Maintain excellent communication with other management and staff members
    • Ability to function effectively under time constraints, consistently meet deadlines and handle multiple tasks in a changing work environment.
    • Ability to attend meetings and travel overnight.
    • Computer proficiency with ability to utilize common computer applications – Microsoft program, Word, Excel, PowerPoint.
    • Strong interpersonal, time management, project management and organization skills.
    • Ability to prioritize and coordinate multiple responsibilities.

    Knowledge of case management and cost containment

    • Adhering to URAC standards and company policies and procedures
    • Maintain confidentiality- Knowledge of laws and regulations pertaining to HIPPA and PHI
    • Additional projects and duties as assigned



    To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

    • Diploma, Associate or Bachelor’s degree in Nursing, Master’s level (or higher) in a Nursing, Health or Human Services field or equivalent related experience preferred.
    • Current, unrestricted RN/LPN license required
    • CCM, CPHM, CMCN, or CDMS certification preferred
    • Two years of Supervisory or Management experience
    • Managed Care background – Worker’s Compensation, Group Health and or Wellness preferred
    • Knowledge of utilization management, quality improvement, discharge planning, and cost management
    • Knowledge of plan benefits information.
    • Knowledge of the authorization process and procedures.
    • Background in Group Health, Wellness and or Worker’s Compensation law and practices desirable
    • Ability to solve practical problems and deal with a variety of variables
    • Possess planning, organizing, conflict resolution, negotiating and interpersonal skills. 
    • Excellent interpersonal skills and excellent organizational skills
    • Ability to set priorities and work independently is essential
    • Proficient with Microsoft Office applications including Word, Excel, and Power Point

    Equipment Operated/Used:

    • Essential Equipment: Desk, Telephone/Fax, Computer Keyboard, Mouse
    • Essential Tools: Pens, pencil, computer, Keyboard
    • Essential Vehicles: Valid driver’s license required


    Special Equipment or Clothing:

    Professional attire adhering to the Company Dress Code


                                                           MENTAL AND PHYSICAL REQUIREMENTS



    a.  Reasoning development:


              Follow one- or two-step instructions; routine, repetitive task.


               Carry out detail but uninvolved written or verbal instructions; deal with a few concrete                   variables.


               Follow written, verbal, or diagrammatic instructions; several concrete variables.


     X       Solve practical problems; variety of variables with limited standardization; interpret instructions.


               Logical or scientific thinking to solve problems; several abstract and concrete variables.


               Wide range of intellectual and practical problems; comprehend most obscure concepts.

    b.  Mathematical development:


               Simple additional and subtraction; copying figures, counting, and recording.


               Add, subtract, multiply, and divide whole numbers.


     X       Arithmetic calculations involving fractions, decimals, and percentages.


               Arithmetic, algebraic, and geometric calculations.


               Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.


               Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application.

    c.        Language development:


               Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing.


               Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction.


               Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants.


     X       Ability to compose original correspondence, follow technical manuals, and have increased contact with people.


               Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.



    a.        Physical activity required to perform the job:


               Sedentary work:  Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time.  Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.


     X       Light work:

    a.     Exerting up to 20 pounds of force occasionally

    b.     Exerting up to 10 pounds frequently

    c.     Exerting a negligible amount of force constantly to move objects


               (If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).


               Medium work:

    a.     Exerting up to 50 pounds of force occasionally

    b.     Exerting up to 20 pounds of force frequently

    c.     Exerting up to 10 pounds of force constantly to move objects


               Heavy work:

    a.     Exerting up to 100 pounds of force occasionally

    b.     Exerting up to 50 pounds of force frequently

    c.     Exerting up to 20 pounds of force constantly to move objects


               Very heavy work:

    a.     Exerting in excess of 100 pounds of force occasionally

    b.     Exerting in excess of 50 pounds of force constantly to move objects

    c.     Exerting in excess of 20 pounds of force constantly to move objects



    b.       Visual requirements necessary to perform the job:


               Far vision:  clarity of vision at 20 feet or more


     X       Near vision:  clarity of vision at 20 inches or less


     X       Mid-range vision:  clarity of vision at distances of more than 20 inches and less than 20 feet


               Depth perception:  the ability to judge distance and space relationships, so as to see objects where and as they actually are


               Color vision:  ability to identify and distinguish colors


               Field of vision:  ability to observe an area up or down or to the right or left while eyes are fixed on a given point




    2. PHYSICAL EFFORT (cont.)


    c.         Physical activity necessary to perform the job and frequency (e.g., continually, frequently, or occasionally):


          Climbing:      Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion.


          Balancing:      Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.


          Stooping:       Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles.


          Kneeling:       Bending legs at knee to come to a rest on knee or knees.


          Crouching:    Bending the body downward and forward by bending legs and spine.


          Crawling:      Moving about on hands and knees or hands and feet.


          Reaching:       Extending hand(s) and arm(s) in any direction.


          Standing:        Particularly for sustained periods of time.


          Walking:        Moving about on foot to accomplish tasks, particularly for long distances.


          Pushing:         Using upper extremities top press against something with steady force in order to thrust forward, downward, or outward.


          Pulling:          Using upper extremities to extent force in order to drag, haul, or tug objects in a sustained motion.



           Motion:          Using feet to push pedals.


          Lifting:           Raising objects from a lower to a higher position or moving objects horizontally from position to position. This factor is important if it occurs to a considerable degree and requires substantial use of the upper extremities and back muscles.


    X    Fingering:      Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling.


    X    Grasping:       Applying pressure to an object with the fingers and palm.





















































    2. PHYSICAL EFFORT (cont.)                     


    X    Talking:          Expressing or exchanging ideas by means of the spoken word. Those activities in which workers must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.


    X    Hearing:         Perceiving the nature of sounds with or without correction. Ability to receive detailed information through verbal communication and to make fine discriminations in sound, such as when making find adjustments on machined parts.


          Feeling:          Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips.


    X    Repetitive      Substantial movements (motions) of the wrists, hands,

           Motion:          and/or fingers.


















    Disagreeable job conditions to which the employee may be exposed and the frequency (e.g., continually, frequently, or occasionally) of this exposure.






                      OF EXPOSURE









    Temperature extremes









    Equipment movement hazard






    Electrical shock



    Significant work pace/pressure






    Other (specify):                                 










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