Job Description

Job Category:

Nursing - Registered Nurse

Work Shift/Schedule:

8 Hr Morning - Afternoon

Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

Supervises the day-to-day operations of the Utilization Review Department to ensure effective and efficient clinical utilization review services are delivered related to medical necessity reviews, precertification, denial analysis, and other revenue related activities. Promotes cooperation with Utilization Review standards by the medical staff. Works collaboratively with Case Management and Revenue Cycle leaders to support the efforts around delivery of safe patient care and compliant delivery of services while promoting a safe environment at NGHS.

Minimum Job Qualifications

• Licensure or other certifications: Commensurate with professional requirements, successful completion of CCM exam, and currently GA licensed RN.
• Educational Requirements: Associates Degree.
• Minimum Experience: Experience in at least one (1) major component of Utilization Management or Case Management. Experience working with third party payers and Physicians. Experience and knowledge in healthcare Federal and State regulations is required.
• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications:
• Preferred Educational Requirements: Bachelors Degree Nursing, Business Health, Management, etc.
• Preferred Experience: Previous leadership and/or supervisory experience. Experience of the Utilization Review area within a mid-large hospital (200+ beds) or five (5) or more years experience in hospital clinical/financial operations and management.
• Other:

Job Specific and Unique Knowledge, Skills and Abilities

• Excellent written and verbal communication skills with the ability to communicate effectively and diplomatically with multi-disciplinary team.
• Supervisory or managerial experience including hiring, training, coaching, and counseling of employees.
• Experience in developing processes, standard workflows, procedures, and policies that positively impact efficient utilization review standards and reimbursement.
• Strong computer skills with the ability to use Microsoft Office, including, but not limited to Microsoft Excel and Word; be able to create spreadsheets, review/sort data, create formulas and word processing.
• Working knowledge of criteria for Medicare, Medicaid, HMO and private insurance coverage; knowledgeable of Federal and State regulations and hospital finance.
• Knowledgeable of Utilization Review principles and Case Management models, along with principles of quality assurance/improvement.
• Must be detail-oriented, able to work independently and possess strong organizational skills with the ability to prioritize multiple issues, tasks and projects while meeting defined timeframes.

Essential Tasks and Responsibilities

• Provides supervision of the day-to-day operations of Utilization Review (UR) for precertification, admission, concurrent and retrospective reviews; Report quality of care issues identified during UM process.
• Functions as a clinical resource for the department and internal staff, demonstrating a thorough knowledge of all Utilization Review policies, procedures, and government insurance programs. Also serves as a resource for administrators and contracted vendors.
• Develops, updates, maintains and communicates UR policies and procedures to ensure positive impact and reimbursement in accordance with the mission, values and strategic goals of the organization.
• Assists in the recruiting and onboarding of new hires, orients, and continuously trains employees to ensure success in their role and a thorough understanding of the necessary policies, processes, and procedures of the UR role.
• Develops and performs quality audits on UR staff to ensure accuracy of work on a monthly basis
• Assists in the development of staff performance expectations, metrics, and goals and holds self and staff accountable to achieving. Establishes and communicates performance and behavioral standards and follows the appropriate disciplinary courses of action when counseling staff. (Accountable to KPIs and metrics set by Sr. Management - see Key Performance Indicators section above)
• Reviews daily, weekly and monthly reports to monitor and analyze performance of department, assess data against KPI standards and goals, and identifies trends. Makes adjustments where needed. Keeps leadership, staff, and clinical staff (where appropriate) informed.
• Works closely with Case Management to ensure effective department collaboration. Identifies and maintains good relationships with other departments such as Managed Care, Patient Financial Services, Patient Access, and others so to facilitate the utilization review processes and to provide continuity of care.
• Collaborates with medical staff and hospital personnel as appropriate to ensure effective coverage and precertification requirements are met.
• Communicates with and educates physicians as needed regarding Utilization Review policies, practices, and procedures to ensure safe, effective services, along with appropriate transitions of care for hospital patients at time of discharge.
• Provides staff counseling and disciplinary action as necessary and/or required.
• Performs staff performance evaluations and provides clear, accurate, and objective feedback for employees in adherence to NGHS policies and guidelines.
• Manages employee payroll for the UR team and ensures timeliness and accuracy of administration.
• Assesses departmental workload to determine appropriate staff allocations to ensure productivity standards are being met consistently.
• Works closely with physicians and staff to provide and monitor clinical/financial data for the purpose of improving hospital/Physician performance and anticipating payer and managed care demands.
• Participates in the Daily Management System (DMS) Quest for Excellence initiative and is responsible for process improvement efforts to improve reimbursement and quality outcomes. Leads daily team huddles in an up-beat, positive, and professional manner.

Physical Demands

• Weight Lifted: Up to 20 lbs, Frequently 31-65% of time
• Weight Carried: Up to 20 lbs, Frequently 31-65% of time
• Vision: Moderate, Frequently 31-65%% of time
• Kneeling/Stooping/Bending: Occasionally 0-30%
• Standing/Walking: Constantly 66-100%
• Pushing/Pulling: Constantly 66-100%
• Intensity of Work: Occasionally 0-30%
• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.