Utilization Review Lead

Job Description: RN - Utilization Review Lead

Job Purpose:

Key Responsibilities:

• Provide support, education, and guidance for other UR RNs and direction for Social Workers.
• Lead multidisciplinary rounds as directed by the ACU/CM Manager.

• Review medical records to determine and document medical necessity for inpatient and observation status using established criteria.
• Identify issues and variations in utilization, escalating concerns to appropriate healthcare team members.
• Actively support initiatives that promote effective resource use.
• Develop and coordinate discharge plans in collaboration with the healthcare team, incorporating patient priorities.
• Identify patients at risk for post-hospitalization problems and collaborate with Social Services for appropriate referrals.
• Advocate for necessary services and funding to meet care plan goals.
• Arrange appropriate community services while adhering to state and federal health regulations.
• Monitor patients' conditions and responsiveness to interventions.
• Communicate effectively with patients, staff, other departments, and providers to ensure needs are met.
• Foster professional relationships with managers, physicians, and hospital staff.
• Utilize effective communication and conflict resolution skills to support the team in addressing difficult interactions.
• Accept delegated responsibilities from the ACU/CM Manager.

• Manage utilization management, clinical coordination, palliative care, and discharge planning for assigned patient areas.
• Collaborate with Emergency Department (ED) physicians and staff to determine appropriate admission levels and support social admissions as necessary.
• Assist the ACU/CM Manager in managing daily/monthly budget performance and productivity.
• Support medical records and patient accounts with chart and charge capture reviews as directed.
• Lead daily multidisciplinary care rounds to ensure safe discharge plans, delegating as needed.
• Work collaboratively with departments in reviewing coding, utilization, and discharge issues.
• Maintain positive relationships with post-hospitalization care organizations and ensure compliance with external requirements.
• Prioritize patients based on intensity, need, and required follow-up; assist in developing support systems.
• Collaborate with healthcare team members and insurance case managers to facilitate care and optimize outcomes.
• Ensure appropriate documentation of utilization management data and review Clinical Documentation Specialist reports.
• Review clinical appeals with UR Physician or third-party Physician Advisor to address documentation issues.
• Maintain positive interdepartmental relationships and serve as a role model for the team.
• Facilitate orientation processes for new staff members and assist in developing staffing plans as needed.
• Assist in establishing departmental onboarding processes, competency evaluations, and collaboration with Nurse Educator.

Qualifications:

• Current Registered Nurse (RN) license in the state of Washington.
• Bachelor’s degree in Nursing preferred; equivalent experience may be considered.
• Minimum of [insert years] years of experience in Utilization Review or related field.
• Strong understanding of CMS regulations and compliance standards.
• Excellent communication, leadership, and interpersonal skills.

Benefits:

• Competitive salary based on experience.
• Comprehensive benefits package including health insurance, retirement plans, and paid time off.