Supervisor, Nursing Utilization Review

We are recruiting for a motivated Supervisor, Nursing Utilization Review to join our team!

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Department

Hospital Care Mgmt

Job Summary

The Supervisor, Nursing Utilization Review is responsible for the clinical and operational leadership of the utilization review team to ensure the accurate and timely authorization of healthcare services. This position reports to the Director of Revenue Integrity and participates in planning, implementing and managing existing and new Utilization Management programs, policies and procedures. Ensures compliance with all policies and procedures, as well as compliance with all state, federal, regulatory and payor requirements. Directs patient assignments and staff scheduling according to census demands and assists in meeting utilization, financial, quality and patient satisfaction targets by effectively assisting in managing utilization, productivity, personnel and supplies. Works collaboratively with multiple interdisciplinary teams including, but not limited to, the Utilization Management Physician Advisors, the Revenue Integrity teams, Compliance, and other Revenue Cycle functions. Prepares and conducts audits, education, and provides feedback and assistance to staff on routine cadence.

Essential Functions:

• Team Leadership & Performance Management ◦ Directly supervise RN utilization management staff; manage schedules, assignments, and productivity during Workday. Conducts daily rounds, monitors work queues and assignments with staff daily to ensure appropriate coverage. ◦ Monitors staff workload, reviews productivity, conducts quality reviews/audits. ◦ Supports the execution of team performance goals in support of organizational initiatives and in collaboration with the Director of Revenue Integrity. ◦ Promotes team and individual process improvements with coaching, case studies, and team meetings. ◦ Track performance and quality measures using dashboards and reports. Analyzes monthly Utilization Management data for best practice and process improvement. ◦ Develops and delivers education to the team to strengthen performance and knowledge for continuous team development. Support onboarding and all continuous learning needs for the team. ◦ Participates in the hiring, orienting, training, performance reviews, counseling, disciplining and terminating of employees. (30%)
• Clinical & Operational Oversight ◦ Monitors and evaluates Utilization Management, work in partnership with UM Physicians, staff and applicable key stakeholders to reduce inappropriate overutilization of services. ◦ Leads the team as a subject matter expert with the ability to answer clinical questions related to utilization review and provide support on case reviews. Maintain expertise through ongoing case review as necessary. ◦ Participates in the clinical denial and appeal process, in partnership with the Revenue Integrity and Billing teams. Review denials reason codes and draft appeal letters with a consolidation of clinical information to advocate for the appropriate status of the patient and resources utilized. ◦ Reviews complex utilization cases and guide the team in applying the appropriate medical necessity criteria and/or payer policies to determine necessary actions. ◦ Escalates findings and engage the necessary leadership to address issues in a timely and productive manner. (30%)
• Compliance & Regulatory Monitoring ◦ Provides daily staff oversight and direction on Utilization Management processes to ensure compliance with all governmental and accredited agencies. Monitor compliance with all utilization management regulatory requirements. Ensure adherence to regulatory turnaround times for Utilization Management decisions. ◦ Participates in the development, refinement, implementation, and administration of Utilization Management programs, policies, procedures, and standard work. Maintains compliance with established hospital policies, procedures, objectives, safety, environmental and infection control guidelines. Support and guide staff to meet compliance benchmarks and timely documentation. ◦ Protects Patient Rights as they pertain to the ethical and legal issues of confidentiality during the case management and utilization management process. ◦ Helps prepare for and assists with internal audits and all external regulatory and compliance reviews (e.g., CMS, URAC, NCQA). (15%)
• Collaboration & Communication ◦ Responsible for effective collaboration with internal and external