RN - Utilization Review Lead - DH

Description

Job Purpose:

The Utilization Review RN, Lead is responsible for the oversight, planning, direction and coordination of

Utilization Review (UR) services of the Care Management Department under the leadership of the ACU/CM

Manager. The Utilization Review RN, Lead is responsible for compliance with all CMS regulations.

Responsibilities include staffing as UR RN, training others in Utilization Review and Utilization Management,

including, but not limited to performance management, improvement plans, and policies

Leadership Duties

Provides Utilization Review support, education and guidance for other UR RNs, and education and direction for

Social Workers, as relevant to their responsibilities. Leads the multidisciplinary rounds as directed by the Manager

of ACU/CM.

Duties

• Reviews medical records for determination and documentation of medical necessity for inpatient and/or

observations status utilizing established criteria and methods.

• Identifies issues and variations in utilization and escalates to appropriate members of the health care team.

Actively supports measures that promote effective use of resources.

• Develops and coordinates discharge plans with input and involvement of health care team.

• Incorporates priorities and decisions made by patients. Implements discharge plans in partnership with

staff RNs.

• Identifies patients at risk for encountering problems post hospitalization and collaborates with Social

Services for referral to appropriate discipline team members and outside agencies to support best patient

outcomes.

• Advocates for services and funding as appropriate and necessary to meet care plan goals.

• Identifies care plans and arranges for appropriate services, applying knowledge of services available in the

community, while adhering to state and federal health regulations. Demonstrates knowledge of procedures

which assure quality care and effective utilization of hospital services; applies this knowledge when

coordinating discharge plans and reviewing medical records.

• Monitors the patient's condition and responsiveness to their interventions.

• Communicates effectively and works collaboratively with patients, staff, other departments and providers

to ensure that patient needs are being met.

• Fosters professional, positive, and collegial relationships with managers, physicians and other hospital

staff members.

• Uses effective communication, problem identification and effective conflict resolution.
Assists in supporting the team in addressing difficult interactions.
• Other duties as assigned. Accepts delegated responsibilities from the Manager of ACU/CM
• Manages and coordinates utilization management, clinical coordination, palliative care and discharge planning for assigned patient areas.
• Collaborates with the Emergency Department (ED) physicians, staff, and social worker to determine admission level of care.
• Collaborates with the ED physician, admitting physician, and ED MSW using the guidelines set forth for potential social admissions, to best meet the needs of the patient and the organization.
• Assists Manager of ACU/CM in managing the daily/monthly budget performance, including productivity.
• Assists medical records and patient accounts with chart and charge capture review, as directed by Manager of ACU/CM.
• Leads daily multidisciplinary care rounds. Ensures safe discharge plans. May delegate leadership of the care rounds to another RNCM when necessary.
• Works collaboratively with other departments (Medical Records, Admitting, Patient Accounts and Compliance) in the review of coding, utilization and discharge issues.
• Participates in developing and maintaining positive relationships with post hospitalization care organizations.
• Maintains compliance with external requirements.
• The Manager of ACU/CM may delegate the CM/UR/SW monthly schedule to the Lead CM/UR RN.
• Prioritizes patients according to intensity, need, and required follow-up. Assists the patient to identify and/or develop a support system and encourages the patient to utilize their support system.
• Collaborates with physicians, other healthcare team members including inpatient facilities, the patient's…