Utilization Review Nurse Lead-RN

To maintain high-quality, medically necessary, evidence-based care, and efficient treatment of all patients, regardless of payment source, by ensuring the patients receive the right care, at the right time, in the right place. 

Case Management Model: utilize an Integrated Case Management Model. Under this model the Case Managers will follow patients through the continuum while facilitating the functions of utilization review, utilization management, and cost containment. Track and trend denials and payor issues to provide feedback and education to payer relations and the case management department.

Completes audits, scheduling, and assignments for designated team members.

Assists with orientation process for new employees.

Escalates issues of concern to management.

Aides as a resource for team.

Daily communication with management team.

Collaborates with other department leads for efficiency.

 

Demonstrate understanding of evidenced based medical necessity criteria. Maintains efficient methods of monitoring the medical necessity and appropriateness of hospital admissions.

Compliance with all Medicare regulatory requirements

Work with external payers completing/securing authorization for services provided to bedded patients.

Monitors cases for appropriateness of continued stay, level of care and services, and quality of care using approved screening criteria. Communicate with physicians when alternatives to inpatient care are indicated by clinical review. 

Monitors identified cases needed for second level of review- facilitates process for referring cases to the Physician Advisor that do not meet established guidelines for admission or continued stay.

Consistent collaboration with the Case Management and Social Work leadership team to prevent extended length of stays and appropriate status determination.

Identifies potential delays in service or treatment and refers to the appropriate individuals within the multidisciplinary patient care teams for action/resolution.  

Identifies problems related to the quality of patient care and refers such problems to the Performance Improvement Department.

Responsible for collaborative review of but not limited to identified medical necessity denials issued concurrently and retrospectively for authorization and experimental/investigational denials.

 

Monitors compliance with documentation methods for monthly reporting and statistics for presentation to the Utilization Review Committee.

Identifies and reports system and process issues and other opportunities for improvement to Payer Relations, Revenue Cycle, and Case Management department. 

Liaison to the Denials/Appeals team regarding identified payer trends and processes impacting concurrent denials and intent to deny.

Interfaces with patient registration and patient financial services etc. to collaborate on financial issues.

Establish a rapport and relationship with third party payers to promote cost effective clinical outcomes. Utilizes opportunities to evaluate changes in payer processes

 

Develops educational programs/job aids to assist department members in the utilization of electronic systems e.g. Epic and the respective modules that promote the workflow of the department.

Works with the Epic teams to develop tools e.g. work queues, documentation tools, reports to improve the department’s system utilization. 

Collaborates with RN Case Manager Lead regarding orientation of new staff.

Maintains departmental education reports as a component of staff performance and as requested by leadership.

Represents Case Management and Social Work on hospital-wide councils related but not limited to technology, education and program developments.

 

Performs other duties as assigned, including but not limited to:

• Demonstrates professional responsibility required in a leadership role

• Complies with department and hospital policies at all times

• Maintains compliance with State/Federal Guidelines and standards

• Conforms to all requirements of Medicare as information is available.

• Keep current on changing laws and requirements of Medicare and Medicaid as available.

• Demonstrate a positive attitude at all times     

KNOWLEDGE AND SKILLS: