RN Concurrent Utilization Review Lead

SUMMARY:

Supports Clinical Utilization team’s work through education and oversight of Concurrent Utilization Review staff in their daily duties. Serves as experienced Concurrent Utilization subject matter resource for inter- & intra-departmental needs.  May function as secondary leadership resource in support of Clinical Utilization Manager duties.

ESSENTIAL FUNCTIONS:

Serves as expert internal resource for Concurrent Utilization RNs and other Clinical Utilization staff through providing secondary review insight (verbal and/or via established Standard of Work for medical necessity review documentation).

Provides analysis and feedback on process improvement activities, develops and presents focused educational programs for staff, both individually and in group settings.

Partners with leadership team on community and hospital wide initiatives focused on reducing length of stay and ensuring hospital patients are in the right status, for the right reason, at the right time.

Collaborates in ongoing evaluation and improvement of Utilization Management processes and functions, to meet the changing needs and priorities of the organization as well as Centers for Medicare and Medicaid Conditions of Participation.

Reports malfunctions with equipment, applications, EMR, etc. & obtains assistance as indicated. 

Refers cases appropriately to Physician Advisor, obtains second level determination and ensures appropriate documentation is present in the medical record. 

Maintains confidentiality of all patient information following TMC and CMS HIPPA guidelines. 

Discusses patient status and care with physician team and nursing staff as appropriate. Collaborate with staff, physicians, care/service coordinators, payers, patients, and their families to coordinate and provide the level of care necessary to meet member’s health need.

Utilizes InterQual® or equivalent evidence-based Clinical Utilization assessment system to document reviews, assessments and progress notes.  Documents case status in Epic per standard of work. Documents the necessary process for utilization of Condition Code 44 to ensure appropriate patient/patient representative notification and billing.

Provides education addressing potential impact of bed status on payor and case management outcomes to other professional members of the patient care team as appropriate, in coordination with Case Management team members.

Reports any concerns regarding coordination of patient care to the appropriate personnel/process (e.g. Manager, Director, Peer Review, RL®). Supports quality identification and reporting process as key UM initiative. 

Identifies avoidable delays in patient hospital throughput and reports opportunities for process improvement through established pathways.  Participates in throughput taskforce meetings as UM delegate when indicated.

Dynamically assesses team workload to anticipate potential insufficient RN coverage; coordinates with department manager to support completion of department review goals.

Serves on departmental/hospital teams or committees as delegated. 

Attends all other assigned committee/task force meetings unless excused by Director or Manager. 

Maintains established department-level dashboard metrics using real-time UM activity data from Epic, Business Intelligence reporting, and other proprietary values as directed to reflect team’s fulfillment of quantitative goals.

Assumes responsibility for understanding the posted "hard" copies & electronic departmental agency minutes/memos. 

Participates in meetings by taking part in discussions, contributing ideas based on TMC’s best interest rather than own self-interest, volunteering to take on responsibilities, problem solving, facilitating reaching a consensus & fulfilling assigned responsibilities by the deadline. 

Participates in performance improvement data collection and/or problem resolution when assigned. 

Practices cost-effectiveness with judicious use of supplies, equipment and resources. 

Shares information from in-services/workshops/seminars/conferences with departmental team; disseminates information for team implementation.

Follows and maintains compliance with regulatory agency requirements pertaining to UM; completes required regulatory education and disseminates relevant changes to team in timely manner for implementation.

Acts as an education resource to the clinical community and organizational leadership with regards to local, state and federal compliance issues.

Adheres to TMC organizational and department-specific safety, confidentiality, values, policies and standards.

Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication. 

Performs related duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION:  Graduation from a qualified, nationally-accredited nursing program required.  Bachelor’s degree preferred.

EXPERIENCE:  Three (3) years RN nursing experience, preferably in an acute care setting.  One (1) year experience working in an acute care utilization review role within the last 3 (three) years, with documented daily use of InterQual® and/or Milliman Care Guidelines® (MCG®) required. 

LICENSURE OR CERTIFICATION:  Current RN licensure permitting work in the State of Arizona required.  Preferred certifications of the highly-qualified candidate include one or more of the following: InterQual Certified Expert®, Accredited Case Manager® (ACM-RN), Certified Case Manager® (CCM®), Health Utilization Management®, and Health Care Quality and Management® (HCQM®), Case Management Nurse - Board Certified (CMGT-BC®),   MCG Care Guidelines Specialist in Utilization Management®, Certified Coding Specialist (CCS®), Certified Professional Coder (CPC®), and/or Certified Professional-Utilization Review (CPUR®).

KNOWLEDGE, SKILLS, AND ABILITIES: 

·         Ability to troubleshoot customary daily-use office equipment as part of usual job duties.

·         Working knowledge of relevant health data protection requirements, including HIPAA and CMS Conditions of Participation, as they pertain to daily Clinical Utilization work.

·         Skill in evaluating cases and determining appropriate care and status based on current evidence-based criteria.

·         Knowledge of direct patient care and critical care procedures and techniques, tools, and responses required to ensure optimal patient care.

·         Skill in communicating in a clear and concise manner with staff involved in acute care, and physicians to ensure the proper care of patients.

·       Excellent verbal, computer (ability to type 35 - 40 wpm), and written communication skills.

·         Experience working with EPIC or EMR equivalent.

·         Skill in meeting facilitation as well as large and small group presentations.

·         Skill in investigative processes used to gather information and evaluate situations.

·         Skill in the use of computer applications, and statistical analysis using a variety of tools such as Word, Excel, PowerPoint, etc.

·         Skill in using Microsoft Teams or equivalent, Zoom, Vocera, telephone, and/or secure chat to communicate with and provide education to care team members.

·         Ability to analyze complex situations and recommend action plans to address exposure.

·         Ability to manage multiple tasks.

·         Ability to maintain high quality work while meeting strict deadlines. 

·         Ability to prioritize caseload and efficiently complete tasks.

·         Interpersonal skills including: flexibility, compassion, professionalism, teamwork within a remote/time zone diverse staff environment.