<p>RN Manager, Utilization Management - Post Acute</p> <p>SummaCare - 1200 E Market St, Akron, OH</p> <p>Full-Time / 40 Hours / Days</p> <ul> <li>Hybrid after training </li></ul> <p>SummaCare is a Summa Health entity that offers health insurance in northern Ohio. As a regional, provider-owned health plan, SummaCare is based in Akron, Ohio, and provides Medicare Advantage, individual and family and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in the state of Ohio, with a 4.5 out of 5-Star rating for 2025 by the Centers for Medicare and Medicaid Services (CMS). Known for its excellent customer service and personalized attention to members, SummaCare is committed to building lasting relationships. Employees can expect competitive pay and benefits.</p> <p>Summary:</p> <p>Perform duties to conduct and manage the day-to-day operations of the utilization management function for post-acute utilization services. Communicate with staff to facilitate daily department functions including prior authorization for post-acute services related to Long Term Acute Care Hospital (LTACH), Acute Rehabilitation (AR), and Skilled Nursing Facilities (SNF), Discharge Planning and transitions of care. Promotes coordination of members to clinically appropriate settings, and appropriate referrals to SummaCare programs. Meets organizational, operational and service goals related to quality outcomes, member experience, and cost-efficiency.</p> <p>Formal Education Required:</p> <p>a. Bachelor's of Science in Nursing (BSN)</p> <ul> <li>Applicants are required to obtain a Master's degree within three (3) years of employment </li></ul> <p>b. Graduate of a program of professional nursing that is accredited by the Commission on Collegiate Nursing Education (CCNE) or Accreditation Commission for Education in Nursing (ACEN)</p> <p>c. Current license to practice registered nursing in the State of Ohio</p> <p>d. Case Management Certification (CCM, ACM) preferred</p> <p>Experience and Training Required:</p> <p>a. Three (3) years performing post-acute utilization management/ discharge planning activities and minimum of four years relevant clinical experience.</p> <p>b. Experience including prior authorizations, post -acute clinical nursing, health plan management, working knowledge of Medicare and/or Commercial plan designs, and/or experience with clinical regulatory and accrediting guidelines preferred</p> <p>c. Prior management/leadership experience required, preferably in post-acute areas and/utilization management, or health plan management.</p> <p>d. Knowledge of clinical authorization criteria required. Knowledge of InterQual or MCG preferred. Must be knowledgeable of CMS post-acute admission requirement.</p> <p>e. Moderate computer skills and familiarity with Outlook, Word, Excel, PowerPoint required. Able to interpret data reports.</p> <p>f. Knowledge of Epic preferred</p> <p>Essential Functions</p> <p>1.Financials</p> <ul> <li>Plans, prepares, implements and monitors area's operational and capital budgets to ensure sound fiscal management consistent with the goals of Summa Health System. </li><li>Manages productivity within department; minimum target is 100%; meets targets set in assigned area. </li></ul> <p>2.Managing & Leading People</p> <ul> <li>Manages performance and ensures 100% of all required performance appraisals are completed. </li><li>Ensures all staff members complete Mandatory Organizational Education (MOE) training annually. </li><li>Ensures all staff members adhere to established Service Excellence Standards. </li><li>Monitors and manages staffing, turnover and vacancy in assigned departments. </li><li>Ensures continued development and education of self and staff. </li><li>Ensures excellent open communications within the department through regular staff meetings, preparation and distribution of minutes, and other means to keep the department informed on a timely basis. </li><li>Recruits, hires, and oversees additional facility-based care management staff development and implementation of an orientation plan for new staff members, and provides timely feedback. </li></ul> <p>3.Service Excellence</p> <ul> <li>Identifies the direct and indirect customers served by assigned department, determining appropriate products and/or services based upon customers' needs, measuring customers satisfaction and developing actions that continually improve services. </li><li>Ensures staff and self follow Service Excellence Standards of Behavior, including standards for Appearance and Environment, Attitude and Courtesy, Communication, Teamwork, Customer Service, Confidentiality, Safety and Etiquette. </li></ul> <p>4.Planning & Organizing</p> <ul> <li>Plans and organizes all activities under his/her control is an effective manner. Prepares departmental tactical and strategic plans as well as designing appropriate organizational structures for areas of responsibility. Organizes and delegates work in an effective manner, establishes appropriate time frames for completion of work, and provides the necessary leadership to ensure effective work results. </li></ul> <p>5.Performance Improvement</p> <ul> <li>Ensures that his/her department adopts a Total Quality Improvement approach to its work that includes employee empowerment, managing with data, a philosophy of continual improvement, a customer driven attitude and a work methodology that maximizes error prevention. Develops and maintains a complete quality monitoring system throughout their department. </li></ul> <p>6.Relationships with Managers, Peers, etc.</p> <ul> <li>Develops and maintains open, honest and mutually beneficial relationships with their manager, fellow managers, staff and the departments to which he/she provides service. Maintains relationships in a manner consistent with Summa's mission, values and philosophies </li></ul> <p>7.Supports Diversity and Community</p> <ul> <li>Ensures a work environment that promotes and embraces diversity. Works to support and strengthen Summa's service to the community. </li></ul> <p>8.Regulatory Compliance</p> <ul> <li>Complies with regulatory and accreditation requirements through completion of Summa's mandatory organizational education, TJC, Code of Conduct and compliance training. </li><li>Responsible for adherence to applicable regulations in daily activities and work processes. </li></ul> <p>9.Oversees CMS Part C and Data Validation (DVA) Post-Acute reporting. Ensures vendors and network providers are following applicable CMS, ODI, and SummaCare requirements.</p> <p>Other Skills, Competencies and Qualifications:</p> <p>a. Flexible: Ability to adapt to meet business needs.</p> <p>b. Access to own vehicle for occasional travel to area post-acute facilities.</p> <p>c. Population Specific Competency: Ability to effectively interact with patients/customers with the understanding of their needs for self-respect and dignity</p> <p>Level of Physical Demands:</p> <p>a. Light: Exerts up to 20 pounds of force occasionally and/or up to ten pounds of force frequently, and/or a negligible amount of force continuously.</p> <p>Equal Opportunity Employer/Veterans/Disabled</p> <p>$40.74/hr - $61.11/hr</p> <p>The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical.</p> <p>Summa Health offers a competitive and comprehensive benefits program to include medical, dental, vision, life, paid time off as well as many other benefits.</p> <ul> <li>Basic Life and Accidental Death & Dismemberment (AD&D) </li><li>Supplemental Life and AD&D </li><li>Dependent Life Insurance </li><li>Short-Term and Long-Term Disability </li><li>Accident Insurance, Hospital Indemnity, and Critical Illness </li><li>Retirement Savings Plan </li><li>Flexible Spending Accounts - Healthcare and Dependent Care </li><li>Employee Assistance Program (EAP) </li><li>Identity Theft Protection </li><li>Pet Insurance </li><li>Education Assistance </li><li>Daily Pay </li></ul>