Team Lead UR RN Case Manager

3 weeks ago

Dallas, United States Steward Health Care Full time

POSITION SUMMARY:

The Utilization Review Case Manager Lead will work with the Utilization Review Case Manages and other facility staff to coordinate the appropriate information and actions necessary to ensure proper authorizations are obtained for care of patients through nursing job functions. Identifying and reviewing denial patterns while working with UR Managers, UR Educators, and Care Management Team to positively impact outcomes.

KEY RESPONSIBILITIES:

Oversight of the Utilization Review Registered Nurses in assigned area. Responsible for daily assignments to ensure proper coverage for all facilities. Monitoring productivity and conducting team member audits. Identifying areas of improvement in daily processes. Coordinating opportunities for education and workflow optimization. Oversees pre-denial process for facilities assigned to regional area. Follows up on pre-denial metrics monthly to ensure accounts are documented appropriately. Reports pre-denial findings and trends to utilization review managers and other identified facility team members. Assists with staff selection, orientation, training, coaching, counseling, and assessment of performance. Attends scheduled meetings and presents findings/education as needed. Builds relationships with internal and external customers including Care Management staff, patients, medical staff, hospital staff, and other key stakeholders. Promotes internal and external understanding of Utilization Management. Monitors new developments in regulations, policies, and trends, that impact the work environment. Is knowledgeable of criteria for Medicare, Medicaid, HMO, and private insurance coverage in your service area. Gathers and communicates information to insurance carriers on the member’s clinical status and ongoing care needs to secure reimbursement for services provided. Reviews pre-denial cases concurrently to determine next steps in the Utilization Review Process. Communicate appropriately with Utilization Review Team and Case Management team members to ensure patient and payor needs are met. Additional duties as assigned.

REQUIRED KNOWLEDGE & SKILLS:

RN - Registered Nurse Knowledge of InterQual criteria, Milliman Criteria, and Medicare Two Midnight Rule Good organizational skills. Ability to analyze data to determine underling trends. Ability to assist in development and process improvement in obtaining payor authorization and concurrent denials. Manages time effectively, sets priorities, and consistently meets deadlines. Excellent verbal and written communication skills. Ability to effectively interact with insurance companies. Demonstrates initiative and pro-active approach to problem resolution. Performs well independently and on a team. Assumes accountability for demonstrating behaviors consistent with the customer service policy. Works competently with computer based charting and other clinical and non-clinical software programs. Readily adapts to change. Operates office equipment efficiently. Ability to create analytic documentation and presentations. Critical thinking skills required.

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

Education: Associate of Science in Nursing Required, Bachelor’s preferred. CCM/ACM Preferred. Experience (Type & Length): Minimum 3 years’ experience as a utilization review case manager or similar experience. Minimum 1 year experience in a supervisory role. Software/Hardware: Proficient computer skills required, i.e. Word, Excel, Microsoft Office Other: Understanding of the health care delivery setting. Ability to read and communicate effectively in English required, ability to communicate in additional languages preferred.

About Steward Health Care
Over a decade ago, Steward Health Care System emerged as a different kind of health care company designed to usher in a new era of wellness. One that provides our patients better, more proactive care at a sustainable cost, our providers unrivaled coordination of care, and our communities greater prosperity and stability.

As the country's largest physician-led, minority-owned, integrated health care system, our doctors can be certain that we share their interests and those of their patients. Together we are on a mission to revolutionize the way health care is delivered - creating healthier lives, thriving communities and a better world.

Based in Dallas, Steward currently operates more than 30 hospitals across Arizona, Arkansas, Florida, Louisiana, Massachusetts, Ohio, Pennsylvania, and Texas.

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