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Lead, Inpatient UM Nurse Capped
4 months ago
Summary
Provides leadership, support, training, and direction to the Inpatient UM teammates. The incumbent will use clinical judgment to provide utilization management review for inpatient during high volume situations. Provide high quality, cost-effective care to enable patients to achieve maximum medical improvement, while receiving care deemed medically necessary.
Duties and Responsibilities
· Conducts review of the TMs timecard (T&A) and 30-days, 60-days, 90-days, 6-month, and annual performance evaluations for assigned UM TM’s. Provides performance feedback to the UM staff and conducts staff trainings as needed.
· Provides leadership, direction, training, and support to the assigned team and remote Inpatient UM staff.
· Assists in the development and updates department Policies and Procedures, Workflows, and SOP’s as needed.
· Assists in organizing and coordinating Team Meetings and plans team building exercises. Assists in research and gathering of details needed for HP CAP responses; reinforces MPM Policies and provides Corrective Action Plans to staff when needed
· Evaluates appropriateness of care through interpretation of benefits as outlined in Title 22, Medi-Cal Provider Manual, DMHC and/or CMS regulatory requirements, and IPA policies and procedures for each product line.
· Leads the clinical review process for assigned team and assigned remote Inpatient UM staff and escalates any issues identified during rounds to the Inpatient UM Supervisor
· Monitors daily workload, daily open cases for nurses to assess and determine staffing needs
· Ensures minimum productivity standards are met, including assisting with current workload when timely review and/or discharge may be in jeopardy.
· Works with other MPM departments to resolve issues relating to authorization of medical services and assists Inpatient UM staff with member’s grievances.
· Leads Inpatient UM staff with the daily huddle with hospitalist, Medical Directors for Outlier Cases: for acute and Skilled Nursing Facility (SNF)
· Assists nurses in identifying and referring eligible cases to the Re-admission Team, Case Management, Transition of Care, Behavioral Health, Post-Discharge Clinics or other internal or external programs (i.e. MedZed, Enhanced Care Management, Community Support services, CAW, Landmark) as needed.
· Reviews Denial Verbiage for nurses to ensure accuracy before Denials are sent to the Denial Team for processing with guidance from the Inpatient UM Nurse Supervisor as needed.
· Provides oversight of DENCs and NOMNCs to ensure accuracy and compliance.
· Responsible for coverage for vacation relief and sick calls, will have modified work assignment.
Minimum Job Requirements
· Knowledgeable of all MPM databases, proper usage, and date fields/ logic used by their team.
· Current RN or LVN licensure; Preferred: BSN level of education.
· Working knowledge of case management philosophy/process/role, needs assessment, principles of utilization review/quality assurance, use of Milliman or other clinical decision support criteria, discharge planning, and reimbursement structures (i.e. Government and non-governmental payers).
Skill and Abilities
· Excellent notetaker with the ability to relay large amount of information in a digestible format and ability to efficiently scrub data to understand errors and/ or key assumptions.
· Ability to identify improvement opportunities and set realistic goals for the TM’s to achieve and mentor TM’s as a coach and tailor their style to each TM personally.
· Ability to communicate effectively with direct TM’s both in meetings and written communication, wide range of hospital personnel, physicians, patients/family members within various socioeconomic groups and representatives of varied outside agencies.
