The Team Lead for Utilization Review (UR) is responsible for the day-to-day activities and oversight of the UR Nurses, under the guidance and support of the Manager of Case Management and Director of the Center. Provides leadership and direction around scheduling, supervision and daily operations, while looking strategically at how workflow and process improvement can optimize and improve the role of Case Management and patient/family care through the institution. Lead will identify challenges and systems issues that need to be elevated to the Manager and Center Leadership.
Team Lead-20%:
Daily clinical support and supervision of UR nurses.
Scheduling for UR coverage.
UR Policies and Procedure review and maintenance.
Onboarding and support of new staff.
Individual and team supervision / support following challenging cases.
Work with Manager to establish and track metrics, data and initiatives that improve process
UR Team Communications.
Assists Manager in completing performance evaluations.
Provides formal and informal support of members through engagement activities, team supervision and staff meetings.
Develop and maintain effective and efficient processes for determining the defensible hospitalization status based on regulatory and reimbursement requirements of various commercial and government payers. -20%
Performs chart review of assigned patients to identify quality, timeliness, and appropriateness of patient care. Conducts hospitalization reviews for Medicaid beneficiaries, as well as other insurers and self-pay patients, based on appropriate guidelines. Uses these criteria to screen for appropriateness of level of care based on medical record documentation. -9%
Gathers clinical information to conduct continued stay utilization review activities with payers pursuant to department policies and procedures and the Utilization Review Plan. -5%
Escalates cases as appropriate for secondary review. -5%
Performs concurrent and retrospective clinical reviews utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies, and timelines. -5%
Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals for secondary review. Identifies, develops, and implements strategies to reduce length of stay and resource consumption in conjunction with discharge planning staff. -9%
Identifies and consistently documents information on any progression of care or patient flow barriers using the designated electronic tool used to track avoidable days/delays. -2.5%
Engages hospital case management and care team colleagues in collaborative problem solving regarding appropriate utilization of resources. -5%
Represents Utilization Management at various committees, as needed. -.5%
Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes. 2
Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities. -10%
Provides consultation and education to physicians and other qualified practitioners regarding medical record documentation necessary to support the ordered level of care. -5%
Conveys benefit data and options, programs and other forms of assistance that may be available to the patient, and negotiates for services as indicated. -.5%
Communicates pertinent reimbursement information to healthcare team while observing patient right to confidentiality. -1.0%
Verifies in-network verses out-of-network benefits and communicates data to the patient and healthcare team as indicated. -.5%
Collaborates with other members of The Center team to coordinate the right care, in the right setting, at the right time for CT Children’s patients.
Identify gaps in care/resources and address issues that negatively impact access to care, services, and resources
Function as a change agent, advocate, and resource person for family and healthcare team to identify and resolve performance improvement issues within the system. -5%
Performs other job-related duties as assigned 0
Education and/or Experience Required:
Education:
Bachelor of Science in Nursing (BSN)
Experience:
3 years’ nursing in a healthcare setting
Education and/or Experience Preferred:
Experience:
Pediatric nursing experience
Previous experience in Utilization Review
Previous experience in Case Management or Discharge planning
License and/or Certification Required:
State of Connecticut Nursing License
License and/or Certification Preferred:
Case Management Certification.
Knowledge, Skills and Abilities:
Knowledge:
Demonstrate working knowledge of how to interpret and apply medical care criteria.
Knowledge of community resources, treatment options, home health availability, funding options and special programs.
UR Team Lead has strong clinical skills and a well-developed knowledge of utilization management, with a focus on medical necessity determinations. Lead maintains current and accurate knowledge regarding commercial and government payers including regulatory requirements.
Skills:
Coordinates management of care for a specified patient population; follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with hospital standards
Provides ongoing support and expertise through comprehensive assessment, care planning, plan implementation and overall evaluation of individual patient needs.
Skilled in the operation of the computer including proficiency in Microsoft Office Word, ability to use/update Excel spreadsheets and ability to navigate EPIC.
Strong working knowledge of medical necessity tools such as InterQual® and Milliman Care Guidelines® and be proficient in medical record reviews.
UR Lead will support process improvement activities and report key metrics to facility leadership as requested.
The UR Lead will demonstrate an ability to effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment.
Lead will provide support to the hospital’s UM Committee as needed and collaborate with multiple leaders at various levels throughout the organization.
Abilities:
Self-directed/motivated, organized, diplomatic and team-oriented.
Function in a high energy, fast moving environment.
Maintain flexibility as determined by acuity of medical unit.
Prioritize case load.
Collaborate with various disciplines
Communicate effectively and efficiently
Prioritize and manage multiple tasks.
Excellent written and verbal communication skills.