Utilization Management Nurse

Team LeaderHow would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.Work Shift: Day (United States of America)Job Summary:The Team Leader is responsible for coordination and function of a team across the continuum during the patient's acute, chronic and long-term stages of illness for a defined patient population. This includes utilization management, transitional care planning, patient advocacy, education for the patient's /family, and monitoring quality indicators to demonstrate outcomes for the team resulting from the service provided. Collaborates with all team members to provide a comprehensive assessment the patient's plan of care, goal/outcome attainment and continued care needs. It is expected that all RN Clinical Nurses are licensed, knowledgeable and uphold the practice of nursing as outlined by the Georgia Professional Nurse Practice Act and implements the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association. As a member of the patient services team, it is expected that the individual upholds the voice of the patient, system policies and procedures while supporting service excellence goals.Core Responsibilities and Essential Functions:Disposition Planning * Collaboration with Discharge Planner and provides resource information in an appropriate and efficient manner. * Identification and documentation of barriers for timely disposition. * Collaboration with other members of the health care team in planning care appropriate for medical needs. * Understanding of eligibility processes and criteria for both private and public, local, state and federal resources. * Response to referrals from hospital staff, physician offices, community and family to provide resource information, counseling and education to the community. * Allowance for any cultural or religious beliefs in providing service and continuity of care. * Partnership with the patient and significant others (as appropriate) using such appropriate method for setting and purpose (e.g., interdisciplinary rounds, keeping the patient and significant others updated and making the patients goals the focus of the plan of care.) * Exemplary Practice and Outcomes. * Participation in the development of protocols and procedures when called upon or through self-initiation in collaboration with care managers and other members of the health care team to achieve best practice outcomes (i.e. decrease in re-admission rates, avoidable days, adverse events, etc.). * Resources and Support Utilization Management * Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. MCG) * Assesses insurance and coverage issues such as managed care, PPO, HMO, and the identification of preferred providers. * Identifies issues relating to patient class and/or appropriateness of admission and collaborates with physician/physician advisor for resolution * Timely identification and referral for alternative level of care. * Responsible for timely and accurate certification of hospital admission * Provides required information to payors * Monitor and evaluate patient/clients ongoing plan of care and facilitates modification utilizing established screening criteria to determine level of care with documentation in the computerized Utilization Management module * Serves as the Subject Matter Expert (SME) for Utilization Review, MCG, and WQ management in Epic * Assists in training and orientation of new staff members * Manages the daily work schedule for staff * Monitor and evaluate the appropriateness of managed care denials and collaborate with attending physician and managed care representative and Medical Director. * Monitor for compliance of Medicare/Medicaid regulations (e.g. order for patient type for billing, appropriate billing). * Evaluates and negotiates patients needs based on quality, cost and necessity. * Responsible for timely and accurate certification of hospital admission. Identifies the following types of barriers: quality of care; timeliness of care; practice patterns. * Participates and supports performance improvement inclusive of all stakeholders, research and research utilization to promote safe, quality patient care including initiating and/or leading such activities as well as, promoting an inter/intra-disciplinary process and actively supports/participates in shared governance at all levels in the system. * Teamwork and Collaboration and Evidence Based Practice and Research ASSESSMENT * Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. Interqual) * Assesses insurance and coverage issues such as managed care, PPO, HMO, and the identification of preferred providers. * Identifies issues relating to patient type and/or appropriateness of admission and collaborates with physician/physician advisor for resolution Team Leader Responsibilities * Coach, mentor and serve as a resource to the Centralized UM team on in areas of work flow and clinical expertise * Participate in the interviewing process with the Directors & Manager for potential team members. * Lead QA & PI activities for the team * Provide guidance and education during the orientation process ensuring that new team members understand the Centralized UM functions. * Provide input for yearly performance evaluations for team * Assist with ongoing training on new initiatives for the department along with resource manager and directors. * Serves as a preceptor and/or or mentor for other professional and/or students, to ensure that there is a current and future qualified workforce. * Professional Development and Initiative Documentation * Ensure all records are up-to-date and legible. * Complete all Epic UR software screens. * Ensures timely and accurate documentation of clinical reviews and insurance updates as required by payors. * Participates in data collection, poses relevant clinical questions to advanced evidence-based practice. Consults appropriate experts and uses appropriate resources and evidence to address practice questions. * Evidence Based Practice and Research Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct.Required Minimum Education:Associates Nursing or Diploma (Nurse) Nursing or Bachelors Nursing-PreferredRequired Minimum License(s) and Certification(s):All certifications are required upon hire unless otherwise stated.BLS - Basic Life Support or ARC-BLS - Amer Red Cross Basic Life Support or BLS-I - Basic Life Support - InstructorRN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state CompactAdditional License(s) and Certification(s):Required Minimum Experience:Minimum 3 years Clinical Practice/Experience Required and Minimum 1 year with one to two years of Case management/Care Coordination experience PreferredRequired Minimum Skills:Knowledge of Case Management process. Excellent organizational and professional communication skills. Knowledgeable in utilizing screening criteria in review of clinical data with respect to patients/clients needs for health care. Ability to effect change, perform critical analysis, promote client/family autonomy and plan and organize effectively for the continuum of care.Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.