UM Supervisor and Data coordinator

Brown University Health Services • Taunton, MA

72d

About The Position

Reports to the Director of Utilization Management. Subject matter expert on acute utilization management functions for observation patients and current inpatients with an insurance denial. Participates in observation rounds and weekly complex care rounds and collaborates with utilization manager, case manager and case management observation supervisor, to inform on utilization criteria and payor benefits. Ensures efficient and effective delivery of patient care services through the appropriate utilization of healthcare resources. Runs and analyzes utilization management reports to inform processes and educational needs. Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect and Excellence, as these values guide our everyday actions with patients, customers and one another. In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include: Instill Trust and Value Differences, Patient and Community Focus and Collaborate. In addition, our leaders will demonstrate an aptitude for: Ensure Accountability and Build Effective Teams, Drive Vision and Purpose and Optimize Work Processes. By applying core and leadership competencies, leaders help Brown University Health achieve its strategic goals.

Requirements

• Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.
• Graduate of a School of Nursing with current license to practice as a Registered Nurse in the State of Rhode Island.
• Bachelor's Degree required; Masters preferred.
• Minimum 2 years recent acute hospital utilization management or insurance company utilization management experience required.
• Analytical skills necessary to evaluate reports, programs, and procedures.
• Administrative and supervisory skills necessary to address utilization management staff functions in the department and/or assigned clinical area.
• Working knowledge of acute InterQual criteria.
• Demonstrated ability to exercise independent judgment.
• Interpersonal skills necessary to establish and maintain effective working relationships and to supervise and coordinate utilization management activities in the clinical area.
• Strong analytical and interpersonal skills are required to provide guidance to and communicate daily with healthcare professionals, patients and families.
• Must exhibit a collaborative approach and method of communication to interact successfully on a daily basis with a wide and diverse population of both health care providers, insurers, patients and their families.
• Demonstrates knowledge and skills necessary to provide care to patients throughout the life span with consideration of aging processes, human development stages and cultural patterns in each step of the care process.
• Must be proficient in the use of Microsoft Office software including email and Outlook calendar and have basic keyboarding skills.

Responsibilities

• Partners with department physician advisors, utilization management and case management leadership, case managers, utilization managers, and other members of the healthcare team in collaboration with the patient/family to optimize observation care and services.
• Proactively identifies high-risk patients within this patient population and collaborates with case management supervisor to facilitate timely discharge plans and mitigate insurance denials.
• Leads daily UM observation huddles.
• Escalates patients to physician advisors for peer-to-peer discussions with providers to transition care and services to the outpatient setting when appropriate.
• Supports all through-put and capacity management activities for RIH and the Brown University Health System.
• Functions as a liaison to the Epi-center; informs appropriate status and prior authorization considerations.
• Advises on appropriate CDU placement and participates in CDU huddles as assigned.
• Monitors patients identified for potential repatriation.
• Ensures authorization in place when required to transition patient back to referring hospital.
• Reviews all currently admitted patients with an insurance denial and ensures all appropriate notices are delivered timely.
• Informs members of the care team of payor denials and insurance qualifiers that may affect the discharge plan.
• Escalates non-hospital level patients with significant discharge barriers to Utilization director for contracting / single case agreement considerations.
• Acts as a subject matter expert on utilization management matters.
• Provides clinical supervision and work direction to Utilization Management staff as needed.
• Provides education to individual and department staff based on utilization management audits.
• Participates in system-wide 7 day a week coverage for clinical and/or scheduling issues.
• Acts as a change agent by identifying opportunities to improve patient flow and reduce service delays through data tracking, analysis, and follow-up.
• Demonstrates a fundamental grounding in nursing theory and practice with a clinical background within a defined content area.
• Remains current on the latest concepts techniques and methods relative to his/her service.
• Demonstrates knowledge of federal and state utilization management rules and regulations.
• Participates in departmental and/or interdepartmental quality improvement activities as requested.
• Participates in orienting new utilization management staff as requested.
• Participates in ongoing education-related professional activities and affiliations to maintain an advanced level of knowledge of patient care services third party payer and managed care requirements and case management.
• Maintains annual competency in acute Interqual criteria.

Benefits

• Equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

What This Job Offers

• Job Type: Full-time
• Industry: Educational Services
• Education Level: Bachelor's degree