Utilization Review Lead

2 months ago

Anacortes, United States EliteCare Medical Staffing Full time
Job Description: RN Utilization Review LeadPosition Title: RN Utilization Review LeadLocation: Anacortes WADepartment/Unit: Utilization ReviewShift: 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

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