Utilization Management, RN Team Leader - Certified
About The Position
The Utilization Review RN Team Lead Certified is a professional nurse employed by Erlanger Medical Center who oversees and supports the day-to-day processes and responsibilities of a team of Utilization Review RNs. The role designs and implements an educational program based on nationally accepted best practices and organizational needs, including training new and existing UR nurses and auditing to identify ongoing educational needs. The incumbent serves as a liaison among Utilization Review staff, Case Management staff, physicians, Patient Financial Services staff, and insurance representatives. The role helps ensure bedded patients have the appropriate admission status and payer approval for the care provided by Erlanger clinical staff. It also oversees communications between Utilization Review and Case Management staff to identify potential patient discharge readiness. The incumbent may represent the department at relevant meetings or committees. The position assigns and coordinates daily work for the Utilization Review RN team and may cover a patient section when staffing is short. It monitors staff adherence to documentation requirements, department processes, and policies. The Team Lead serves as an educational resource for other Utilization Review teams, support staff, and physicians on insurance requirements and Milliman and InterQual criteria. This position reports to the Manager, Utilization Review.
Requirements
- Graduate from an accredited school with an Associate's Degree in Nursing (RN).
- 10 years of nursing experience, including a broad range of clinical nursing and utilization review and/or case management experience.
- Demonstrated ability to work effectively with professionals in diverse disciplines.
- Computer literacy and demonstrated ability to prioritize tasks and timeframes.
- Experience and ability to coach, teach, and manage individuals with different learning mechanisms.
- Current licensure to practice nursing in Tennessee (RN).
- Certified in Milliman and/or InterQual Utilization Management, or required to complete certification within one year of hire.
- For non-Tennessee residents, Tennessee licensure or multistate licensure from a compact state must be obtained within three months of hire.
Nice To Haves
- Bachelor of Nursing (BSN), Master's degree in Nursing, Healthcare Administration, or Business.
- Knowledge of managed care practices and familiarity with regulatory and insurance reimbursement issues.
Responsibilities
- Oversee, support, and coordinate the day-to-day processes and responsibilities of a team of Utilization Review RNs.
- Design and implement an educational program based on nationally accepted best practices and organizational needs.
- Train new and existing Utilization Review nurses and conduct audits to identify ongoing educational needs.
- Act as a liaison among Utilization Review staff, Case Management staff, physicians, Patient Financial Services staff, and insurance representatives to support appropriate admission status and payer approval.
- Oversee communications between Utilization Review and Case Management staff to identify potential patient discharge readiness.
- Represent the department in relevant meetings or committees when requested.
- Assign and coordinate daily work for the Utilization Review RN team and cover a patient section when staffing shortages require it.
- Monitor assigned staff's documentation adherence and compliance with department processes and policies.
- Provide education to Utilization Review teams, support staff, and physicians regarding insurance requirements and Milliman and InterQual criteria.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
Education Level
Associate degree
