UR RN Lead Case Manager
The Lead Care Manager is responsible for assisting with all the daily operations of the Central Utilization Review (UR)- Care Management Department. The Lead assists the Corporate Centralized Director in employee supervision, management, and training; data research and analysis; development and implementation of quality initiatives designed to support defined objectives. Guides team in resource management. Maintains the standard for a collaborative process of assessment, planning, facilitation and advocacy for patients in our care. Individualizes services to meets patient's health care needs by utilizing available resources to promote quality outcomes. The Lead Care Manager will act in the role of a staff UR/Care Manager when needed.
- Assists Director with the daily operations of the Care Management Department.
- Serves as the Utilization Review Subject Matter Expert. that UM practices and supporting documentation are compliant with all regulatory requirements. The Incumbent also serves as a Subject Matter Expert
- Assists with scheduling staff in compliance with productivity measurements.
- Participates with department audits, both internal and external.
- Assists with staff selection, orientation, training, coaching, counseling, and assessment of performance.
- Leads the treatment team in understanding, monitoring and effective utilization of hospital resources.
- Actively prevents medical necessity denials by submitting referrals to physician advisor for status review. Documents in CM system. Discusses recommendations with physicians. Ensures updated documentation occurs post discussion.
- Screens all transfers to/from other facilities for appropriate placement and level of care. Further ensures transfers from the ED are in compliance with EMTALA. Assists in providing appropriate Memorandum of Transfer for all patients transferring to another facility are completed. Documents in CM system.
- Refers potential quality issues to Care Management leadership, Risk Management, Pharmacy, or Infection Control.
- Monitors for compliance to Federal, State and JC requirements. Takes action when deficiencies are found.
- Attends committee meetings as directed.
- Attends scheduled meetings and performs presentations as needed/designated.
- Builds relationships with internal and external customers including Care Management staff, patients, medical staff, hospital staff, and other key stakeholders.
- Promotes internal and external understanding of Utilization Management.
- Collaborates with the Business Office and onsite eligibility worker, where patients require assistance with financial matters.
- Establishes relationships and effectively collaborates with revenue cycle production units to support continuous improvement aligned with Steward Healthcare management expectations.
- Keeps UM Leadership apprised of departmental and industry trends, deficiencies, and any potential risks, and collaborates with the team to develop and execute mitigation efforts.
- Monitors new developments in regulations, policies, and trends, that impact the work environment.
- Is knowledgeable of criteria for Medicare, Medicaid, HMO, and private insurance coverage in your service area.
- Gathers and communicates information to insurance carriers on the member’s clinical status and ongoing care needs to secure reimbursement for services provided.
- Participates in the development of Case Management practice standards and executes consistent standards of care.
- Demonstrates initiative to seek new knowledge and expand professional practice.
- Participates in educational programs relevant to scope of practice.
- Conducts informal and formal educational programs within the Steward Healthcare System related to utilization review and case management processes.
- Participates in various ad-hoc denials task forces and teams, including denials recovery, root cause and account research, denials reporting, and denials prevention initiative teams.
- Reviews pre-denial cases concurrently to determine next steps in the Utilization Review Process (Case Management Utilization Standards)
- Identifies denial patterns and works with Utilization Review RN Team Lead/ Supervisor to positively impact outcomes
- Will direct Utilization Review authorization coordinator regarding Peer to Peer calls/ scheduling and organizing.
- Performs other duties as requested.
REQUIRED KNOWLEDGE & SKILLS:
- RN - Registered Nurse
- Previous experience in Case Management including knowledge of Interqual criteria, Milliman, Medicare Two Midnight Rule and Utilization Management preferred.
- Skills include the ability to review cases for appropriate status of care, continued stay and the utilization of discharge screens.
- Possess strong communication, problem solving and organizational skills.
- Must be proficient in word processing and the use of clinical software.
- Knowledge and Experience with Electronic Health Records: Meditech knowledge beneficial
- Clear Communication Skills Both Written and Verbal
- Bachelor’s Degree in nursing or Associate Science in Nursing
- CCM or ACM Preferred or obtained within 2 years of employment
- Minimum of three (3) years’ experience in care management, discharge planning position involving care management, utilization review responsibility, in an acute care hospital and/or managed care setting.
- Two + years of management/leadership, project lead or subject matter expert
- Must possess a thorough working knowledge of Medicare, Medicaid and managed care utilization review requirements. Must be familiar with federal and state accreditation standards as they relate to care management and utilization review.
- Able to Withstand Crisis Situations
- Has Skills to Provides Customer Service to Patients, Team Members And Visitors
- Strong collaboration, communication and interpersonal skills
- Excellent organizational and time management skills
- Knowledge of computers, Electronic Health Records, data base systems and utilization review/case management documentation systems
- Desire to work collaboratively and proactively with healthcare teams and other hospital interdisciplinary teams
- Excellent written/verbal communication skills, critical thinking skills, creative problem-solving skills, good organizational and planning skills
- Must be self-directed, have the ability to tolerate frequent interruptions and work in a fast-paced work environment Knowledge of funding, resources, services, clinical standards, utilization review processes and outcomes is preferred.
- Able to Keep Confidential Information Regarding Patients, Team Members