Utilization Management Team Lead RN

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Work Shift

Day (United States of America)

Job Summary:

The Team Leader is responsible for oversight of staff UM RNs to ensure 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, patient advocacy, and monitoring quality indicators to demonstrate outcomes for the team resulting from the service provided. Collaborates with all team members to optimize hospital's throughput, length of stay, and reimbursement accuracy. The Team Lead of On-site UM is responsible for Training, Supervision, and Coordination of On-site UM staffing. Provides direction/assistance to all UM Staff, students and WellStar customers. The Team Lead of On-site UM will assist with overall coordination of the department's goals, process improvements, policies and procedures. 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. As an on-site Hospital Utilization Management (UM) Nurse Team Lead, you are the primary link between the clinical floor and administrative compliance. Unlike remote roles, this position relies heavily on real-time, face-to-face interaction with doctors, patients, and interdisciplinary teams to optimize hospital resources. Key On-Site Responsibilities Physician and Clinical Collaboration o Physician Consultation: Meet in person with attending/admitting providers to discuss cases where documentation does not support medical necessity or the current level of care. o Medical Provider Liaison: Function as the primary on-site link between the attending/admitting provider and the Physician Advisor for complex medical necessity determinations. Real-Time Patient Class Decision Support o Interdisciplinary Huddles: Attend daily bedside rounds or departmental "bed huddles" to provide immediate input on medical necessity and criteria-led care progression. o ER Throughput Management: Provide consultation as needed on cases being admitted through the Emergency Department to assess new admissions and recommendations for the most appropriate level of care. Administrative & Financial Compliance o Medical Necessity Reviews: Use criteria like InterQual or MCG to perform on-site concurrent reviews of active patient care. o Issuing Official Notices: Deliver and explain legally required documents in person, such as condition-code 44 or Medicare observation notices (MOON). o Denial Prevention: Proactively identify "avoidable days"hospital days that do not meet clinical criteriaand escalate them to the management team to minimize financial loss.

Core Responsibilities and Essential Functions:

Team Lead Duties Coordinate care care with Manager, Director and other Healthcare Team Leaders. Oversee staffing daily staffing/ evaluates daily work distribution regarding levels & demands of staff. Daily monitoring and coaching of staff productivity and denial ratios, reports for daily volume without medical reviews completed, management of Epic WQs, peer to peer outcomes, E.H.R use with outcomes, avoidable days documentation and reporting, and barriers impacting utilization management workflow Supervise, coach, mentor on general practice. Head a team of peers to participate in the interviewing process with the Directors. Manage QA & PI activities Provides leadership in conflict resolution Provide guidance during the orientation process ensuring that the new employee is firmly educated in UM and Social Service issues. Assists with yearly performance evaluations Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education. 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. 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 such as managed care, PPO, HMO, and the identification of preferred providers for OON payors. * Identifies issues relating to patient class and/or appropriateness of admission and collaborates with physician/physician advisor for resolution Provide consultation as needed on cases being admitted through the Emergency Department to assess new admissions and recommendations for the most appropriate 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). * Responsible for timely and accurate certification of hospital admission. * 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. Assessment Initiates assessment for necessity and appropriateness of health services by the application of established screening criteria (e.g. MCG). Assess insurance and coverage issues such as managed care, PPO, HMO, and the identification of preferred providers. Assess insurance and coverage issues such as managed care, PPO, HMO, and the identification of preferred providers. 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. Deliver and explain legally required documents in person, such as condition-code 44 or Medicare observation notices (MOON). Proactively identify "avoidable days"hospital days that do not meet clinical criteriaand escalate them to the management team to minimize financial loss. Professional Development and Initiative Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education. Serves as a preceptor and/or or mentor for other professional and/or students 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

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

• RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact
• BLS - Basic Life Support or BLS-I - Basic Life Support - Instructor or ARC-BLS - Amer Red Cross Basic Life Support

Additional License(s) and Certification(s):

CCM within 90 Days Preferred

Required Minimum Experience:

Minimum 3 years Clinical Practice/Experience Required and Minimum 1 year with one to two years of UM/Case management/Care Coordination experience Required

Required Minimum Skills:

Knowledge of Case Management process. High Excellent organizational and professional communication skills. High Knowledgeable in utilizing screening criteria in review of clinical data with respect to patients/clients needs for health care. High Ability to effect change and perform critical analysis. High

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