Job title: LEAD UTILIZATION REVIEW NURSE (REMOTE)
Company: LifeBridge Health
Job description: LEAD UTILIZATION REVIEW NURSE (REMOTE)
- Baltimore, MD
- SINAI HOSPITAL
- UTILIZATION REVIEW
- Full-time – Day shift – 8:00am-4:30pm
- RN Other
- Posted: January 11, 2024
The Lead UR Nurse serves as a clinical resource and lends guidance to Utilization Review staff in concurrent and retrospective review, utilization care management and denials and appeals programs. Assists Director of Case Management with implementation, maintenance and evaluation of an integrated care management program. Supervises the general operations of focused utilization review area(s).
Clinical Resource: Utilizes experience and expertise to guide staff. Tasks: Provides oversight, training, guidance, and assistance to staff regarding concurrent review, retrospective review, write-offs, appeals and denial and case management intervention. Supports and models customer service expectations. Exemplifies LifeBridge values. Maintains a written workflow for each type of utilization review. Maintains a process for entering clinical reviews in the EMR. Provides a system for identifying reviews that are due. Provides a priority system for review that assures adherence to deadlines and maximizes care management activity. Updates staff regarding changes in acute care criteria and review processes. Updates staff regarding regulatory changes (CMS/DHMH). Assists in procuring resources for staff to allow the staff to execute the work. Provides guidance and functions as a resource to staff regarding care progression and inpatient acute criteria meetings.
Program Management: Assists and supports director to manage and evaluate effectiveness of utilization review program as well as prevent denials. Tasks: Works with Director and staff to develop processes to carry out the Utilization Management Plan and recommendations of the Utilization Management Committee. Assists with operations to ensure timely review and prevent denials. Attend and participates in team meetings. Assists Director with committees that address utilization, denials and appeals. Functions as a contact person for insurance programs and other internal departments such as Patient Access and Patient Financial Services, resolving problems, and coordinating educational and working meetings. Assists Director in representation of the Utilization Management area in internal and external meetings and projects.
Supervision: Oversees the daily operations of the focused Utilization Review area in conjunction with the AVP. Oversees the staffing schedule and assignments to assure that deadlines are met, resources are maximized and the budget is followed. Assists AVP with development and completion of performance evaluations for assigned Utilization Review staff by providing feedback regarding skill, productivity, and compliance with department processes. Assists in the execution and follow-up of action plans. Assists AVP with identification of utilization problem trends and implementation of related action plans. Monitors and supports compliance with review processes and priority systems and related procedures. Monitors and reports effectiveness of review processes and priority systems. Assists with denial prevention by working to identify issues preventing payment; interacting with related departments to remedy issues potentially causing denials.
Reports: Manages and works the write-off report for focused areas as assigned and collaborating with other team members such as denial and appeals nurses. Works with the quality analyst to track, trend and report utilization issues with a focus on length of stay and insurance denials for the AVP, Utilization Management Committee, and health care team. Prepares reports for AVP/UM Committee by request. Prepares documents, copies materials, and distributes materials to support information flow of UM area. Tracks work from write-off report and follows cases through to completion of reimbursement. Provides reports reflecting this work as requested.
Professional Development: Keeps self abreast of changes in regulations and individual payer operations. Attends scheduled updates regarding regulations, payer meetings. Shares this information with appropriate parties. Shares new information with staff and provides any routine updates. Special Projects Other duties as assigned to assist with expediting length of stay, ensuring utilization review, and preventing denials.
QUALIFICATIONS AND REQUIREMENTS:
- Basic professional knowledge; equivalent to a Bachelor’s degree; working knowledge of theory and practice within a specialized field; Bachelor’s degree required
- 3-5 years of relevant experience
- Maryland Registered Nurse License required (RN)
- Case Management Certification (CCM) is preferred
Additional Information As one of the largest health care providers in Maryland, with 13,000 team members, We strive to CARE BRAVELY for over 1 million patients annually. LifeBridge Health includes Sinai Hospital of Baltimore, Northwest Hospital, Carroll Hospital, Levindale Hebrew Geriatric Center and Hospital and Grace Medical Center, as well as our Community Physician Enterprise, Center for Hope, Practice Dynamics, and business partners: LifeBridge Health & Fitness, ExpressCare and HomeCare of Maryland.
Location: Baltimore, MD
Job date: Mon, 29 Jan 2024 08:57:35 GMT