Utilization Review Lead
Utilization Review Lead
Posted on :
26-09-2024
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1 Vacancy
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Job Description
Job Description: RN Utilization Review Lead
Position Title: RN Utilization Review Lead
Location: Anacortes WA
Department/Unit: Utilization Review
Shift: 8 Hour Variable
Job Purpose:
The Utilization Review RN Lead is responsible for the oversight planning direction and coordination of Utilization Review (UR) services within the Care Management Department. Reporting to the ACU/CM Manager this role ensures compliance with all CMS regulations and supports effective utilization of resources throughout the healthcare continuum.
Key Responsibilities:
Leadership Duties:
- Provide support education and guidance for other UR RNs and direction for Social Workers.
- Lead multidisciplinary rounds as directed by the ACU/CM Manager.
Core Responsibilities:
- Review medical records to determine and document medical necessity for inpatient and observation status using established criteria.
- Identify issues and variations in utilization escalating concerns to appropriate healthcare team members.
- Actively support initiatives that promote effective resource use.
- Develop and coordinate discharge plans in collaboration with the healthcare team incorporating patient priorities.
- Identify patients at risk for posthospitalization problems and collaborate with Social Services for appropriate referrals.
- Advocate for necessary services and funding to meet care plan goals.
- Arrange appropriate community services while adhering to state and federal health regulations.
- Monitor patients conditions and responsiveness to interventions.
- Communicate effectively with patients staff other departments and providers to ensure needs are met.
- Foster professional relationships with managers physicians and hospital staff.
- Utilize effective communication and conflict resolution skills to support the team in addressing difficult interactions.
- Accept delegated responsibilities from the ACU/CM Manager.
Additional Duties:
- Manage utilization management clinical coordination palliative care and discharge planning for assigned patient areas.
- Collaborate with Emergency Department (ED) physicians and staff to determine appropriate admission levels and support social admissions as necessary.
- Assist the ACU/CM Manager in managing daily/monthly budget performance and productivity.
- Support medical records and patient accounts with chart and charge capture reviews as directed.
- Lead daily multidisciplinary care rounds to ensure safe discharge plans delegating as needed.
- Work collaboratively with departments in reviewing coding utilization and discharge issues.
- Maintain positive relationships with posthospitalization care organizations and ensure compliance with external requirements.
- Prioritize patients based on intensity need and required followup; assist in developing support systems.
- Collaborate with healthcare team members and insurance case managers to facilitate care and optimize outcomes.
- Ensure appropriate documentation of utilization management data and review Clinical Documentation Specialist reports.
- Review clinical appeals with UR Physician or thirdparty Physician Advisor to address documentation issues.
- Maintain positive interdepartmental relationships and serve as a role model for the team.
- Facilitate orientation processes for new staff members and assist in developing staffing plans as needed.
- Assist in establishing departmental onboarding processes competency evaluations and collaboration with Nurse Educator.
Qualifications:
- Current Registered Nurse (RN) license in the state of Washington.
- Bachelor s degree in Nursing preferred; equivalent experience may be considered.
- Minimum of insert years years of experience in Utilization Review or related field.
- Strong understanding of CMS regulations and compliance standards.
- Excellent communication leadership and interpersonal skills.
Benefits:
- Competitive salary based on experience.
- Comprehensive benefits package including health insurance retirement plans and paid time off.
Why Join Us At EliteCare Medical Staffing we value passion for providing highquality care. We offer a supportive environment where you can grow professionally. If you are ready to make a difference in patients lives and advance your career we encourage you to apply!
Application Process: Interested candidates should submit their resume and a cover letter outlining their qualifications and interest in the position to Insert Application Email/Link.
communication,patient advocacy,conflict resolution,rn,medical records review,compliance,utilization review,nursing education,coordination,rnp,leadership,planning,discharge planning,budget management,interpersonal skills,staffing management,insurance case management,communication skills,clinical coordination,cms regulations
Employment Type
Full Time
Key Skills
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