Job Title
You supervise utilization review for RNs. You oversee processes daily. Guide on complex cases. Identify staff education opportunities. Connect departments through communication.
Essential Functions of the Role
- Supervising Utilization Review Department, assigning tasks, assessing productivity, conducting quality reviews, and advising team on peer-to-peer appeals. Also conducting denial research.
- Collecting data to generate weekly reports that aid in improving staff outcomes and enhancing quality metrics.
- Collaborate with the Medical Director and Care Coordination when patients don't meet criteria. Updating Clinical Resource Manager as needed.
- Assigning daily tasks to staff members to ensure service levels are maintained at an optimal level.
- Monitors daily observation reports to identify and address any potential problems.
- Handling escalations from Utilization Review Nurses and other staff members.
- Conducting quality reviews as needed.
- Responding to inquiries from staff members and stakeholders regarding Utilization Review.
- Serve as a Subject Matter Expert (SME) for Utilization Review workflow issues, complex cases, denials, and customer interactions, both internal and external.
Key Success Factors
- Possessing a helpful nature that assists others in identifying and solving challenges.
- Skilled in mentoring and encouraging colleagues for the enhancement of their clinical proficiency.
- Exceptional written and conversational abilities.
- Proficient at collaborating effectively with employees of varying ranks, including those at the highest level of leadership.
- Familiarity with discharge planning, case management, and utilization review. processes, case handling and the review of resource usage.
- Experience in strategically directing work among team members based on established policies and protocols.
- Aptitude in making sound hiring and termination suggestions.
- Proficiency in training colleagues and assessing their performance.
- Basic digital skills like using Microsoft Office, information security, managing schedules and payroll, electronic medical documentation, and email use
Qualification
- EDUCATION - Associate's Degree
- MAJOR - Nursing
- EXPERIENCE - (4) Four Years of Experience