Team Lead Utilization Review, Galv. Campus Utilization Mgt

2 weeks ago

Galveston, United States UTMB Health Full time

Team Lead Utilization Review, Galv. Campus Utilization Mgt

Galveston, Texas, United States

New

Nursing & Care Management

UTMB Health

Requisition # 2404190

MINIMUM QUALIFICATIONS:

  • Graduation from an accredited school of professional nursing with a Bachelor of Science in Nursing andcurrent Texas Nursing licensure as a professional registered nurse.

  • Minimum of five years full-timewage-earning experience as a professional nurse in a health care setting.

  • Minimum of 2 years UtilizationReview experience.

JOB SUMMARY:

Expert Utilization Review nurse—possess an in-depth knowledge and skill level to be a resource to other Utilization Review Nurses and staff. This includes an understanding of Centers for Medicare and Medicaid Services (CMS) rules, The Joint Commission standards and other regulatory requirements. Must possess an extensive understanding of the Level of Care (LOC) review criteria. This role is intended for the advanced Utilization Review Nurse, who in addition to their routine assignment, takes on initiatives to enhance the betterment of the overall department. This individual will serve as the mentor for other Utilization Review Nurses in regard to the guidance and management of complex cases. In this role the Team Lead will collaborate and promote team atmosphere with Care Coordinator and Social Work colleagues.

ESSENTIAL JOB FUNCTIONS:

  • Serve as a subject matter expert in all facets of Utilization Review

  • Work in collaboration with Manager and administrative assistance to plan orientation schedule for new staff members

  • Provides oversight of all new hires and ensures competency prior to releasing from orientation

  • Ensure iSpace is updated regularly as revisions are made to processes, job descriptions, policies, procedures, workflows, etc.

  • Provide weekly written progress reports to Manager and updated training outline plan with all new hires accordingly

  • Once new hire is assigned clinical cases, Team Leader will review cases weekly and provide immediate feedback to new staff member

  • Discuss issues or potential opportunities for staff improvement/development with Manager

  • Works collaboratively with Manager to perform monthly quality audits on clinical utilization review and management.

  • Assist Manager in the creation of the agenda for the Bi-weekly Utilization Review meetings and be prepared to lead in the absence of Manager

  • Assist Manager in preparation of monthly Utilization Review Committee meeting

  • Leads Medicare Short Stay meetings and provides closure on outstanding cases

  • Implement new/revised processes among utilization management staff

  • Oversee workloads by monitoring designated work queues to ensure timeliness in decision making, clinical updates, and closure of cases

  • Discuss variances that may be identified in team member case load/performance with manager, such as: untimely decision, insufficient documentation, no evidence of appropriate referrals

  • Supply ongoing training and education to the staff through meetings, one-on-one, or written resources regarding Level of Care criteria tools, CMS, and other necessary job-related skills.

  • Monitor and provide feedback for obtaining timely clinical updates, completing Level of Care criteria reviews and monitoring the length of stay

  • Assists with special projects or departmental process improvement efforts, as needed

  • Oversee activities conducted by Utilization Review Nurse reviewers and their timely, accurate application of decision criteria

  • Monitor denial correspondence for consistency and accuracy with decisions, member language (when appropriate), and pertinent information. Monitor all correspondence for compliance

  • Functions as a skilled leader, providing direction and assistance to team members

  • Role models professional verbal and non-verbal demeanor

  • Puts needs of others above his/her own through accountability, compassion, integrity and respect

  • Accepts responsibility for professional growth/development

  • Actively utilizes evidence-based practice (EBP), research, and/or quality improvement to enhance organizational initiatives.

  • Communicates with physician or downstream providers on difficult cases that may require increased care coordination

  • Identifies and implements cost containment strategies for the hospital and the patient

  • Provides coverage for staff or leadership as needed

SALARY:

Salary commensurate with experience

Equal Employment Opportunity

UTMB Health strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a VEVRAA Federal Contractor, UTMB Health takes affirmative action to hire and advance women, minorities, protected veterans and individuals with disabilities.

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