Utilization Management RN Lead Job Lincoln area,Nebraska USA,Nursing

Summary

Conducts day-to-day activities for the clinical, financial and utilization coordination of the patient’s hospital experience. Proactively consults with the interdisciplinary team which includes, but is not limited to, hospital patient care staff, physicians, patient support, and family to ensure the patient’s hospital stay meets medical necessity and insurance authorizations are obtained to facilitate the financial well‑being of the patient and hospital.

Acts as the contact for the Utilization Management (UM) staff for day‑to‑day questions and guidance. Shares meeting responsibilities with the manager representing UM in meetings inside and outside the department. Serves as the Subject Matter Expert (SME) for the whole department both inside and outside the department. Assists with scheduling, assigning workflow, and various employee instructions both educational and corrective.

Principal

Job Functions

Commits to the mission, vision, beliefs and consistently demonstrates our core values.

Acts as manager when manager is unavailable.

Serves as the subject matter expert for the Utilization Management department for utilization review activities, including concurrent and retrospective reviews as required.

In conjunction with the manager, assists in streamlining operations and maximization of UM tools.

In conjunction with the manager, attends Operational and Revenue Cycle meetings as needed representing the Utilization Management department, and attends the UM Committee meeting.

Acts as the day‑to‑day contact for the Utilization Department staff to approve last‑minute requests for time off, assists with assignments, schedules, and helps manager with employee situations.

Performs duties as a Utilization Management RN by determining the medical necessity of requests by performing first level reviews and using approved evidence‑based guidelines/criteria.

Takes UM‑RN staff shifts as needed by performing utilization review activities, including concurrent and retrospective reviews as required.

Collaborates with the patient’s provider and other healthcare team members in managing the patient’s length of stay and determining the continuing medical necessity of continued stays.

Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm.

Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow‑up.

Serves as an internal and external resource regarding appropriate level of care; admission status/classification;
Medicare/Medicaid rules, regulations, and policies; third party and managed care contracts; discharge planning; and length of stay.

Ensures appropriate resource utilization relevant to the financial, regulatory, and clinical aspects of care; proposes alternative treatment to ensure a cost effective and efficient plan of care.

Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship.

Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives.

Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

Participates in meetings, committees and department projects as assigned.

Performs other related projects and duties as assigned.

Required Knowledge, Skills, and Abilities

Maintains clinical competency as required for the unit including but not limited to age‑specific competencies relative to patient’s growth and developmental needs, annual skill competency verification and mandatory education and competencies.

Knowledge of governmental and third‑party payer regulations and requirements related to patient hospitalization and acute rehabilitation admission, stay and discharge activities (i.e. CMS).

Knowledge of computer hardware equipment and software applications relevant to work functions.

Skills in conflict diffusion and…