The Lead Utilization Management RN supports and provides oversight including mentoring and leadership to the Utilization Management team on program processes and procedures as well as compliance of regulatory standards. Evaluates Utilization Management department performance and assists the Director of Care Coordination with developing focus areas. Works collaboratively with the Utilization Management Physician Advisor in providing hospital Provider education and participates in the Utilization Review Committee. The Lead Utilization Management RN addresses day to day functions of the Utilization Management team, assists with questions and case reviews for the UR team, assigning and monitoring Utilization Management RN case load assignments along with leading scheduled UR huddles. The primary purpose is to oversee the Utilization Management RN staff and utilization review process to determine legitimacy of admission, treatment, and length of stay in the hospital in order to comply with governmental and commercial insurance company reimbursement policies and procedures.
DUTIES AND RESPONSIBILITIES:
Assesses and monitors the performance of Utilization Management RN's.
Adjusts the workloads of the UM RN's to insure daily targets are being achieved.
Advises and serves as a resource to UM RN's in achieving utilization review objectives.
Advises and assists the UM RN with education and compliant processes to follow Center for Medicare and Medicaid Services regulations along with commercial payer contractual guidelines.
Active member with Utilization Review Committee.
Understands and works directly with the Director of Care Coordination in modifying or initiating payer contractual agreements and updates.
Facilitates mentoring and teaching of compliant UM processes with the UM RN in concurrent or retrospective Utilization Management chart and case reviews to maintain department standards and in conjunction with the UR Plan.
Resolves discrepancies between the UM RN and the patient's payer sources as necessary.
Performs as assigned second level reviews with appropriate follow-up on results.
Leads scheduled Peer to Peer discussions with the UM Physician Advisor as necessary.
Performs quality review activities ie. Reviewing 5 cases per UM RN every month.
Measures UM RN productivity and effectiveness by evaluating other aspects of the UM RN process including participation in multidisciplinary care rounds, payer denials, etc.
Collects and shares ongoing metrics with staff.
Leads, coordinates and maintains an agenda for regularly scheduled Utilization Management huddles.
Confers with Physician Advisor on difficult and complex cases, obtains advice on issues related to Provider compliance with respect to admission status orders and patient medical necessity for admission.
Refers problem cases to Physician Advisor for review.
Participates in meetings with Providers to relay information concerning: UM rule or process changes, payer contract modifications, focus areas for quality outcomes and discussions of admission status orders and purpose.
Acts as resource for policies, procedures, related to Utilization Management.
Uses Midas to monitor and interpret all aspects of UM RN Program and maintains integrity of data collection, ensures accurate data entry, demonstrates competence in navigating in Midas, and utilizes Midas as a resource in ensuring accurate documentation.
Fills in for UM RN when staff are absent, assists UM RN's during spikes in case load, promotes UM RN program, interfaces with multidisciplinary care team to solicit understanding of admission status requirements and medical necessity.
Has current knowledge of healthcare regulations, clinical knowledge of pathophysiology and skills in clinical terminology.
Demonstrates the ability to deal with pressure to meet deadlines, to be accurate, and to handle constantly changing situations.
Demonstrates the ability to deal with a variety of people, deal with stressful situations, and handle conflict.
Adheres to dress code.
Completes annual educational requirements.
Maintains regulatory requirements.
Wears identification while on duty.
Maintains confidentiality at all times.
Attends department staff meetings as required within the department.
Reports to work on time and as scheduled; completes work in designated time.
Represents the organization in a positive and professional manner.
Actively participates in performance improvement and continuous quality improvement (CQI) activities.
Coordinates efforts in meeting regulatory compliance, federal, state and local regulations and standards
Communicates and complies with the Benefis Health System Mission, Vision and Values as well as the focus statement of the department.
Complies with Benefis Health System Organization Policies and Procedures.
Complies with Health and Safety Standards and Guidelines.
Graduate of an accredited nursing college or university degree with active licensure required, BSN Preferred
Two years of utilization review and/or case management experience preferred
Minimum of 5 years of acute care nursing is desired
Knowledge of Medicare and Medicare Managed Care utilization review regulations and medical necessity criteria requirements
Understanding of insurance carrier coverage details
Familiar with federal and state accreditation standards as they relate to Utilization Review
As a not-for-profit community health system, Benefis is driven to provide the highest level of care. We serve nearly 230,000 residents across a 15-county region that is bigger than Connecticut, Massachusetts, New Hampshire and Vermont combined. Benefis is the largest non-governmental employer in the Great Falls area, with more than 3,000 employees.Benefis has 530 licensed beds (that includes 146 beds in long-term care, 71 in assisted living and 20 beds at Peace Hospice of Montana) and partners with over 250 area physicians.Our hospital has been recognized for its exceptional work in quality care by providing a wide range of programs and services to help you live the best life possible. We’re here to help you “Live well.”Benefis Health System came about when two Christian-based hospitals became one. Our founders believed in providing good care to all in need, and trusted that this would be accomplished. The Benefis name was derived using Latin root words: "Bene-" meaning good, and "fis-" for faith and trust. It’s these same root words that make up such terms as ‘beneficial’ and ‘confidence’.Benefis has been a trusted provider of care for more than 125 years. And our name speaks to o...ur commitment: good care one can put faith in.Benefis is consistently ranked among America’s top hospitals by the nation’s leading healthcare ratings organizations for a range of services, including cancer care, joint replacement, stroke treatment, wound care and home health.To learn more about our services, continue looking through our website at WWW.BENEFIS.ORG or call 406.455.5000.