Utilization Review Team Leader, RN

Overview

Under the supervision of the Utilization Review Manager, serves as the Team Leader to the Utilization Review staff. Has the overall accountability for the utilization management. Collaborates with other members of the health care team to identify appropriate utilization of resources and to ensure reimbursement. Utilizes Inter Qual criteria and Dragonfly care level scores as a guideline to confirm medical necessity reviews.

• Serves as team leader for the day to day operations for the Utilization Review Function, providing feedback and direction to staff.
• Overseeing auditing for third party payers.
• Assist in orientation, improvement performance, disciplinary action, and time/attendance.
• Functions as a consultant to utilization review and staff for solving challenging utilization issues, denials, and appeals through the DCH System.
• Assist in denial management.
• Educates the UR team members and care management team in Inter Qual, Jiva, and Dragonfly.
• Monitors the utilization of Commercial observation services.
• Informs staff of any insurance changes involving Inter Qual guidelines, Dragonfly, or in providing clinical reviews.
• Refers cases to the appropriate Physician Advisor due to medical necessity, quality, or delay in service.
• Monitors patient’s clinical course to verify patient’s continued need for acute hospital level of care.
• Negotiates a resolution of any disagreement over the need for acute hospital level of care with the insurer.
• Collaborates with appropriate parties regarding inappropriate admissions, delays in services or discharge, and the over-utilization of hospital resources.
• Maintains records in a complete, detailed, and orderly manner.
• Identifies potentially avoidable days per department policy.
• Educates staff and physicians about managed care principles, observation status, discharge planning, and reimbursement rules.
• Evaluates medical records for appropriateness of admission status utilizing a combination of clinical information, screening criteria, and third party information. Collaborates with the business office as needed.
• Collaborates with all members of the multidisciplinary team to facilitate the utilization review and case management process.
• Supports and participates in department strategies and efforts focused on improving clinical documentation by physicians and staff.
• Conducts special focus reviews as directed.
• Supports departmental operations to ensure consistency with health system/department policies.
• As a member of the utilization review practice:
  • Seeks and provides peer consultation about cases that are presenting problems and/or experiencing significant deviation from the plan of care.
  • Participates in quality improvement and evaluation processes related to the case management practice.
• Demonstrates the knowledge and skills necessary to provide care appropriate to the age of patients served.
• Follows Case Management policy regarding Utilization Review process.
• Adheres to DCH Health System facility and department policies and procedures as well as standards from external regulatory agencies and accrediting bodies (i.e., JCAHO, Department of Public Health, QIO, etc...).
• Participates in activities of professional associations as appropriate.
• Participates and assists in departmental studies and projects as assigned.
• Performs basic administrative tasks related to the job, including but not limited to, preparing reports and statistical record keeping.
• Maintains confidentiality of all information.
• Attends mandatory in-service programs.
• Responsible to support and participate in department strategies and efforts focused on improving length of stay (LOS).
• Is knowledgeable of hospital mission, vision, and values and performs in a manner that supports them.
• Identifies and reports Quality and Risk Management concerns.
• Secures appropriate status orders from physicians and documents in medical record.
• Maintains confidentiality at all times related to both patient and employee information.

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee…