Utilization Review Supervisor RN, Central Utilization Review, Full Time, Days

Jackson Health•Miami, FL

1d•Hybrid

About The Position

The Clinical Resource Coordinator is a professional member of the health care team who has 24hour/7day accountability for the coordination, monitoring and management of patient care resources to promote cost effective delivery of patient care services at the appropriate level while maintaining a standard of quality patient care for all patient populations. The Clinical Resource Coordinator acts as a resource to all levels of staff in defining / implementing and evaluating patient care and nursing practice standards utilizing clinical expertise, the nursing process, current concepts/principles of case management/utilization management/disease management, quality improvement, clinical practice and health care trends. This professional member of the healthcare team maintains compliance with current regulatory standards and new regulatory regulations, clinical and financial, and promotes such compliance as part of daily operations amongst all team members. The Clinical Resource Coordinator performs specific job criteria/performance standards according to prevailing applicable Jackson Health System, professional and regulatory standards.

Requirements

Generally requires 3 to 5 years of related experience.
BSN or Bachelor's degree in related field is required.
Must meet and maintain valid and current all unit specific and organizational skills/competencies, certifications/licensures, as required by regulatory and/or nursing standard of practice for the specialty.

Nice To Haves

Current experience as utilization review registered nurse.
Master's degree is preferred.

Responsibilities

Leads the assessment, planning, implementation, and evaluation for new department models and initiatives.
Identifies practice issues, systems issues, and trends utilizing medical criteria, clinical data systems, and protocols.
Performs problem-resolution activities to maintain quality patient care.
Presents at administrative meetings.
Manages Case Management and Social Work metrics and productivity, including but not limited to length of stay (LOS), case mix index (CMI), discharge barriers, resource utilization, discharge planning, and level of care.
Provides management oversight of patient throughput, including assessment and evaluation to determine appropriate level of care and admission status (inpatient, observation, outpatient procedure) from point of entry through discharge.
Follows up in the outpatient setting for patients enrolled in the CRM Placement EDP program.
In the absence of the Manager for Clinical Resource Management, visits facilities to evaluate and determine patient appropriateness for the current level of care as needed.
Works in collaboration with the Manager for Clinical Resource Management to transition CRM Placement EDP program patients to the appropriate level of care as needed.
Provides management oversight of the Clinical Care Coordinator's performance regarding level of care along the continuum (e.g., medication effectiveness, treatments, pain status, discharge plans) and individualizing the plan of care, including reinforcement of teaching and discharge planning.
Maintains leadership visibility, supports service-excellence initiatives, and focuses on improving employee satisfaction.
Rounds on patient units to identify barriers to staff performance and discharge barriers.
Creates and implements Corrective Action Plans (CAP) for problem resolution and escalation of issues preventing efficient performance.
Coordinates day-to-day CRM operations for designated areas, including program development, implementation, outcomes, staffing, liaison with PROS/MCOS/regulatory/community agencies, revenue cycle department, length-of-stay initiatives, Physician Adviser activities, and evidence-based practices.
Provides management oversight for referral and problem resolution of complicated discharges.
May provide management oversight for referral and problem resolution of complex discharges.
Collaborates with family, Attending Physician, Chief Utilization Officer, Utilization Management Committee, and discharge-services providers to ensure a safe discharge plan.
Conducts concurrent review of employee schedules to ensure appropriate staffing coverage based on patient census.
Collaborates with the Chief Utilization Officer regarding the Utilization Management Committee, case-consultation activities, negotiation of patient placement at the appropriate level of care, and evaluation of the patient's medical plan of care.
Demonstrates behaviors of service excellence and CARE values (Compassion, Accountability, Respect, and Expertise).
Performs all other related job duties as assigned.