Description

Job Summary

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