About the Job Candidate must have acute care Utilization Review experience. Candidate must live in the DC/Baltimore region General Summary of Position Supervises the daily activities of the Utilization Review Team. Manages daily assignment ensuring all UM tasks are completed each day.
Collaborates with the physician nurse case manager social worker and other members of the health care team to meet individualized patient outcomes. Assists the Director in managing the daily departmental operations with the goal of maintaining adequate staffing levels and efficient workflow. Acts as a resource and mentor to the Utilization Review staff.
Primary Duties and Responsibilities Supervises daily activities of UM team. Monitors and arranges for adequate staffing to ensure appropriate Utilization Review coverage for units. Monitors daily workflow issues and addresses issues related to workflow in collaboration with the director as necessary.
Acts as a resource and mentor for UM Team. Oversees the orientation of new UR Coordinators by establishing the plan and monitoring progress in conjunction with other staff as necessary Serves as a resource to all staff in areas of utilization review/management. Educates members of health care team through in-services staff meetings orientation and formal educational offerings.
Completes continuing education to maintain knowledge base. Collaborates with and assists the nurse case manager and social worker to meet the patients' continuing health needs in a high-quality cost-effective manner by identifying patients in need of case management. Participates in planning rounds as needed to address and communicate issues related to acuity level of patient LOS insurance and discharge needs.
Collects quality improvement data in accordance with approved indicators. Monitors and audits staff UM reviews for completeness and compliance with standards. Recognizes potential problems and provides education to staff.
Utilizes research methods to collect tabulate and analyze data in collaboration with the case management team medical staff and hospital performance improvement initiatives. Assists CM Leadership in implementing strategies to correct or modify trends seen through data analysis and outcome monitoring. Confers and collaborates routinely with the physician advisor and attending physicians to resolve problems regarding acuity and level of care.
Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations. Identifies insurance information obtains authorization communicates with financial counseling and assigns appropriate length of stay for admission.
Implements strategies to avoid denials including potential denial notification to attending physician. Issues letter of non-coverage for Medicare or third-party payers according to policies and procedures. Communicates utilization plans to case management team.
Evaluates concurrent and retrospective denials for appeal opportunities. Generates appeal letters based on knowledge of clinical severity and intensity. Manages the department in the Director's absence.
Keeps Director informed about issues related to staffing and problem areas. Keeps Director informed about issues related to quality risk patient/family issues and concerns allocation of resources and vendor/payer issues. Assists the Director in monitoring performance issues.
Contributes to the performance evaluation process by giving feedback to the Director and helping create professional development plans for UR Coordinators. Participates in multidisciplinary quality and service improvement teams. Performs admission reviews and subsequent concurrent reviews to determine the necessity for acute care by application of accepted criteria based on age specific needs.
Interacts with and assists third party payer reviewers to facilitate appropriate care and ensure payment of services. Performs concurrent and retrospective reviews telephonically as required. Completes all forms and documentation necessary to support appropriate utilization of resources.
Minimal Qualifications Education Bachelor's degree in Nursing required Experience 3-4 years clinical experience in acute care setting required 2 years Case Management or Utilization Management experience preferred 1-2 years leadership experience preferred Licenses and Certifications RN - Registered Nurse - State Licensure and/or Compact State Licensure the District of Columbia or State of Maryland depending on work location required CCM - Certified Case Manager preferred This position has a hiring range of USD $89,065.00 - USD $162,801.00 /Yr.