Role: Utilization Review RN, Lead

Sign-On Bonus $5,000,

Location: Anacortes, WA 98221

Fulltime/Permanent

Job Category: Care Management

Job Purpose:

The Utilization Review RN, Lead is responsible for the oversight, planning, direction and coordination of Utilization Review (UR) services of the Care Management Department under the leadership of the ACU/CM Manager. The Utilization Review RN, Lead is responsible for compliance with all CMS regulations.

Responsibilities include staffing as UR RN, training others in Utilization Review and Utilization Management, including, but not limited to performance management, improvement plans, and policies

Leadership Duties

Provides Utilization Review support, education and guidance for other UR RNs, and education and direction for Social Workers, as relevant to their responsibilities. Leads the multidisciplinary rounds as directed by the Manager of ACU/CM.

Duties

• Reviews medical records for determination and documentation of medical necessity for inpatient and/or observations status utilizing established criteria and methods.

• Identifies issues and variations in utilization and escalates to appropriate members of the health care team. Actively supports measures that promote effective use of resources.

• Develops and coordinates discharge plans with input and involvement of health care team.

• Incorporates priorities and decisions made by patients. Implements discharge plans in partnership with staff RNs.

• Identifies patients at risk for encountering problems post hospitalization and collaborates with Social Services for referral to appropriate discipline team members and outside agencies to support best patient outcomes.

• Advocates for services and funding as appropriate and necessary to meet care plan goals.

• Identifies care plans and arranges for appropriate services, applying knowledge of services available in the community, while adhering to state and federal health regulations. Demonstrates knowledge of procedures which assure quality care and effective utilization of hospital services; applies this knowledge when coordinating discharge plans and reviewing medical records.

• Monitors the patient’s condition and responsiveness to their interventions.

• Other duties as assigned.

Accepts delegated responsibilities from the Manager of ACU/CM

Manages and coordinates utilization management, clinical coordination, palliative care and discharge planning for assigned patient areas

• Collaborates with the Emergency Department (ED) physicians, staff, and social worker to determine admission level of care.

• Collaborates with the ED physician, admitting physician, and ED SW using the guidelines set forth for potential social admissions, to best meet the needs of the patient and the organization.

• Assists Manager of ACU/CM in managing the daily/monthly budget performance, including productivity.

• Assists medical records and patient accounts with chart and charge capture review, as directed by Manager of ACU/CM.

• Leads daily multidisciplinary care rounds. Ensures safe discharge plans. May delegate leadership of the care rounds to another RNCM when necessary.

• Works collaboratively with other departments (Medical Records, Admitting, Patient Accounts and Compliance) in the review of coding, utilization and discharge issues.

• Participates in developing and maintaining positive relationships with post hospitalization care organizations.

Skills/Qualifications:

• Demonstrates leadership and communication skills consistent with IHospital’s Purpose, Focus and Values, and displays the ability to motivate and engage others to achieve desired outcomes.

• Plans, organizes and prioritizes skills with demonstrated evidence of critical thinking, problem solving and analytical processing ability.

• Self-motivates and has the flexibility and ability to work independently, with strong ethical standards.

• Adapts to facilitate change while meeting multiple demands and priorities of a challenging position and workload.

• Develops and maintains strong interpersonal relationships with staff at all levels of the organization with a focus on forming partnerships with key stakeholders to achieve an optimal patient care experience and support Hospital’s strategic goals.

Work Environment:

The work of this position is performed inside, exposing the employee to indoor environmental conditions, protected from weather conditions but not necessarily from temperature changes. The employee may be exposed to dust, pollens, pollutants, fumes, communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations and other conditions common to a health care environment. The noise level in the work environment is usually moderate.

Job Type: Full-time

Pay: $45.00 - $60.00 per hour

Expected hours: 40 per week

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Travel reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Day shift

Experience:

• Utilization review: 1 year (Preferred)

License/Certification:

• RN (Preferred)

Work Location: On the road